Implementation of a countywide adult suicide review commission: Development, lessons learned, and recommendations.

INTRODUCTION: Fatality review is a public health approach designed to inform efforts to prevent fatalities of a certain kind (e.g., suicide, homicide) or in a specific setting or population (e.g., hospitals, youth). Despite extensive literature on fatality review generally, the literature on suicide review teams specifically is scant. The aim of this paper is to: describe the implementation of a local adult suicide review commission, detail examples of initial outcomes and recommendations developed by the commission, and provide recommendations and/or best practices for how to develop and implement an adult suicide review team. METHODS: We utilize framing questions from the American Association of Suicidology's psychological autopsy framework. By using these guiding questions in the discussion, members are invited to explore not only the stressors that may have more immediately preceded the suicide event itself, but to situate those stressors in the context of the individual's life course. RESULTS: Several recommendations proposed by our commission have resulted in tangible outcomes and are detailed using Haddon's Matrix as a guiding prevention planning tool. IMPLICATIONS: We have highlighted the need to move beyond looking at individual-level help-seeking to focus on structural/systemic issues that result in stress or create unsafe environments for at-risk individuals.

Strengthening the Role of the NIH in the Firearm Violence Epidemic: A Modest Proposal.

This Viewpoint discusses the potential for the National Institutes of Health (NIH), the premier research entity in the world, to significantly strengthen its investment in preventing and reducing firearm-related harms.

Risk of deaths due to injuries in travellers: a systematic review.

BACKGROUND: Annual global travel reached an all-time high of 1.4 billion international tourist visits in 2019. It is estimated that injury accounts for close to 25% of deaths in travellers, most of which are theoretically preventable. However, there are limited data available on injury occurrence and outcomes in travellers. Our objective was to better understand the relative risk of dying from injury that arises from the novel environments and behavioural changes associated with foreign travel. METHODS: A systematic literature review was conducted (PubMed, Embase and Scopus) according to PRISMA guidelines that included studies published in English since 1990 that reported injury deaths in tourists per 100 000-person years or as a proportion of total tourist deaths in comparison to a non-traveller population. We also included studies that reported data allowing calculation of these rates. Relative rates or proportions of overall injury mortality, mortality due to traffic accidents, drowning and homicide were summarized. RESULTS: In total, 1847 articles were identified, 105 underwent full-text review, and 10 articles were suitable for data extraction. There was great variability of relative risk reported, but overall, travellers appear to have a higher risk of injury mortality than domestic populations, with relative rates of injury death ranging from 1.04 to 16.7 and proportionate mortality ratios ranging from 1.43 to 3. CONCLUSIONS: Tourists should be aware of the increased risk of dying from road traffic hazards, drowning and homicide while traveling abroad. Specific geographies and activities associated with higher risk should be emphasized. Travel medicine practitioners and organizations that send people abroad should counsel travellers regarding these risks and seek ways to reduce them, including encouraging potential risk-mitigating behaviours. There is a need to improve systems of data collection and reporting on injury deaths in travellers and to study the impact of pre-travel and institutional interventions aimed at reducing this risk.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies.

OBJECTIVE: To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC). BACKGROUND: A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury. METHODS: We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms. RESULTS: We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76). CONCLUSIONS: Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

The Association Between Repealing the 48-Hour Mandatory Waiting Period on Handgun Purchases and Suicide Rates in Wisconsin.

IMPORTANCE: Suicide is a significant public health burden in the United States. There is little understanding how policies regarding gun purchasing affects suicide rates. Wisconsin state legislature rescinded a 48-hour waiting period for handgun purchases, which took effect in June 2015. OBJECTIVE: To determine whether firearm-related suicide increased with the repeal of the 48-hour waiting period for handgun purchases in 2015. METHOD: We obtained data through the Wisconsin Department of Health Services via the Wisconsin Interactive Statistics on Health Query System. Suicide rates were compared by Comparative Mortality Figures (CMF). RESULTS: We reviewed all suicides in Wisconsin between 2012-2014 and 2016-2018. The rate ratios (R) and second generation P values (pδ) comparing deaths between 2012-2014 and 2016-2018 indicate significant increases in firearm-related suicide among people of color (R = 1.927; pδ = 0.0) and among Wisconsinites residing in urban counties (R = 1.379, pδ = 0.0). There was no significant increase in non-firearm-related suicide (R = 1.117, pδ = 0.092), nor in firearm-related suicide among White non-Hispanics (R = 1.107, pδ = 0.164) or Wisconsinites residing in rural counties (R = 1.085, pδ = 0.500). CONCLUSION: Our findings suggest that the repeal of the 48-hour waiting period on handgun purchases in 2015 is correlated with the increase of firearm-related suicides among Wisconsin residents of color and Wisconsinites residing in urban counties.Key Messages:Firearm policies are associated with changes in suicide rates.

Prevention of Firearm Injuries Among Children and Adolescents: Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium.

IMPORTANCE: Firearm injuries are the second leading cause of death among US children and adolescents. Because of the lack of resources allocated to firearm injury prevention during the past 25 years, research has lagged behind other areas of injury prevention. Identifying timely and important research questions regarding firearm injury prevention is a critical step for reducing pediatric mortality. OBJECTIVE: The Firearm Safety Among Children and Teens (FACTS) Consortium, a National Institute for Child Health and Human Development-funded group of scientists and stakeholders, was formed in 2017 to develop research resources for the field, including a pediatric-specific research agenda for firearm injury prevention to assist future researchers and funders, as well as to inform cross-disciplinary evidence-based research on this critical injury prevention topic. EVIDENCE REVIEW: A nominal group technique process was used, including 4 key steps (idea generation, round-robin, clarification, and voting and consensus). During idea generation, stakeholders and workgroups generated initial research agenda topics after conducting scoping reviews of the literature to identify existing gaps in knowledge. Agenda topics were refined through 6 rounds of discussion and survey feedback (ie, round-robin, and clarification steps). Final voting (using a 5-point Likert scale) was conducted to achieve consensus (≥70% of consortium ranking items at 4 or 5 priority for inclusion) around key research priorities for the next 5 years of research in this field. Final agenda questions were reviewed by both the stakeholder group and an external panel of research experts not affiliated with the FACTS Consortium. Feedback was integrated and the final set of agenda items was ratified by the entire FACTS Consortium. FINDINGS: Overall, 26 priority agenda items with examples of specific research questions were identified across 5 major thematic areas, including epidemiology and risk and protective factors, primary prevention, secondary prevention and sequelae, cross-cutting prevention factors, policy, and data enhancement. CONCLUSIONS AND RELEVANCE: These priority agenda items, when taken together, define a comprehensive pediatric-specific firearm injury prevention research agenda that will guide research resource allocation within this field during the next 5 years.

Gun Violence: A Biopsychosocial Disease.

Gun violence is a complex biopsychosocial disease and as such, requires a multidisciplinary approach to understanding and treatment. Framing gun violence as a disease places it firmly within medical and public health practice. By applying the disease model to gun violence, it is possible to explore the host, agent, and environment in which gun violence occurs, and to identify risk factors to target for prevention. This approach also provides an opportunity to address scientifically inaccurate assumptions about gun violence. In addition, there are many opportunities for medical communities to treat gun violence as a disease by considering and treating the biologic, behavioral, and social aspects of this disease. The medical community must answer recent calls to engage in gun violence prevention, and employing this model of gun violence as a biopsychosocial disease provides a framework for engagement.

Workplace violence in emergency medicine: current knowledge and future directions.

BACKGROUND: Workplace violence (WPV) has increasingly become commonplace in the United States (US), and particularly in the health care setting. Assaults are the third leading cause of occupational injury-related deaths for all US workers. Among all health care settings, Emergency Departments (EDs) have been identified specifically as high-risk settings for WPV. OBJECTIVE: This article reviews recent epidemiology and research on ED WPV and prevention; discusses practical actions and resources that ED providers and management can utilize to reduce WPV in their ED; and identifies areas for future research. A list of resources for the prevention of WPV is also provided. DISCUSSION: ED staff faces substantially elevated risks of physical assaults compared to other health care settings. As with other forms of violence including elder abuse, child abuse, and domestic violence, WPV in the ED is a preventable public health problem that needs urgent and comprehensive attention. ED clinicians and ED leadership can: 1) obtain hospital commitment to reduce ED WPV; 2) obtain a work-site-specific analysis of their ED; 3) employ site-specific violence prevention interventions at the individual and institutional level; and 4) advocate for policies and programs that reduce risk for ED WPV. CONCLUSION: Violence against ED health care workers is a real problem with significant implications to the victims, patients, and departments/institutions. ED WPV needs to be addressed urgently by stakeholders through continued research on effective interventions specific to Emergency Medicine. Coordination, cooperation, and active commitment to the development of such interventions are critical.

Motor vehicle crashes associated with alcohol: child passenger injury and restraint use.

BACKGROUND: The role of alcohol in fatal motor vehicle crashes involving children has been well established. However, the nonfatal injury burden of alcohol on child passengers has not been comprehensively assessed. PURPOSE: This study sought to determine injury burden and restraint use in child passengers aged 1-15 years in alcohol-related motor vehicle crashes. METHODS: A retrospective cohort study including all people involved in all crashes with an injury or at least $1000 property damage occurring in Wisconsin in 2007 and involving at least one child passenger aged 1-15 years. RESULTS: A total of 22,464 child passengers were involved in motor vehicle crashes in Wisconsin in 2007; 2.5% (n=570) were in alcohol-related crashes. Child passengers in alcohol-related crashes experienced twice the risk of injury compared to non-alcohol-related crashes (risk ratio [RR]=2.42, 95% CI=2.08, 2.80). Two-vehicle crashes that were alcohol-related were more than two times more likely to result in child injury than those that were not (RR=2.78, 95% CI=2.30, 3.35). In alcohol-related crashes, the risk of injury in children was higher if they were passengers in the alcohol-related vehicle compared to the non-alcohol-related vehicle (RR=1.35, 95% CI=1.01, 1.79). Inappropriate restraint of child passengers was higher in alcohol-related vehicles (34.5% vs 17.1%, p<0.00005), particularly in the group aged 4-7 years (70.8% vs 44.9% inappropriately restrained). CONCLUSIONS: Motor vehicle crashes resulting from alcohol-related driving significantly increased child passenger injury and were associated with inappropriate child passenger restraint. Several evidence-based policies are recommended to address this public health problem.

Communicating emerging infectious disease outbreaks to the public through local television news: public health officials as potential spokespeople.

OBJECTIVE: To assess how West Nile virus (WNV) was reported to the American public on local television news and identify the main factors that influenced coverage. METHODS: A representative sample of WNV stories that were reported on 122 local television news stations across the United States during October 2002, covering 67% of the nation's population, were coded for self-efficacy, comparative risk scenarios, symptoms and recommendations, high-risk individuals, and frame. In addition, public service professionals (PSPs) interviewed in the segments were identified. Comparisons were made between stories in which a PSP was interviewed and stories without an interview with respect to discussion of the 5 variables coded. RESULTS: Of the 1,371 health-related stories captured during the study period, 160 WNV stories aired, the second most common health topic reported. Forty-nine of the 160 WNV stories contained at least 1 of the 5 reporting variables. Forty-two PSPs were interviewed within 33 unique WNV stories. Public health officials composed 81% of all PSP interviews. Stories containing a public health official interview had 15.2 times (odds ratio 15.2, confidence interval 5.1-45.9) higher odds of reporting quality information, controlling for station affiliate or geographic location. CONCLUSIONS: Emerging infectious disease stories are prominently reported by local television news. Stories containing interviews with public health officials were also much more likely to report quality information. Optimizing the interactions between and availability of public health officials and the local news media may enhance disaster communication of emerging infections.

Developing a global research agenda on violence and injury prevention: a modest proposal.

The need for the development of a global injury prevention research agenda is examined. Literature was reviewed in public health and selected policy strategies outside of public health that address the development of research agendas both for specific injury topics as well as for other health related areas; the benefits of creating a global research agenda are highlighted. There are examples of successful strategies where the development of a global research agenda on an injury specific topic has improved knowledge and prevention activities in that subfield. There are also examples that consolidate larger health topics and follow an agenda. Such efforts can benefit from wider governmental and institutional support. It is concluded that the development of a global injury prevention research agenda focused on collaborative efforts and with emphasis in implementation and dissemination research could be a useful tool to improve the quantity and quality of research in the field.

Injury deaths of US citizens abroad: new data source, old travel problem.

BACKGROUND: Global travel continues to increase, including among US citizens. The global burden of injuries and violence, accounting for approximately 5 million deaths worldwide in 2000, is also growing. Travelers often experience heightened risk for this biosocial disease burden. This study seeks to further describe and improve our understanding of the variable risk of travel-related injury and death. METHODS: Information on US civilian citizen deaths from injury while abroad was obtained from the US Department of State Web site. This information was categorized into regional and causal groupings. The groupings were compared to each other and to injury deaths among citizens in their native countries. RESULTS: From 2004 to 2006, there were 2,361 deaths of US citizens overseas due to injury. Of these US citizen injury deaths, 50.4% occurred in the Americas region. Almost 40% (37.8%) of US citizen injury deaths in the low- to middle-income Americas were due to vehicle crashes compared to about half that (18.9%) (proportional mortality ratio [PMR] = 1.72, 95% confidence interval [CI] 1.59-1.62) for low- to middle-income Americas citizen injury deaths. Similar differences between US citizen injury death abroad and the in-country distributions were also found for vehicle crashes in Europe (35.9% vs 16.5%, PMR = 2.17, 95% CI 1.78-2.64; p < 0.0005), for drowning deaths in the Americas (13.1% vs 4.6%, PMR = 2.67, 95% CI 2.29-3.11) and many island nations (63.5% vs 3.5%, PMR = 11.38, 95% CI 8.17-15.84), and for homicides in the low- to middle-income European countries (16.9% vs 10.5%, PMR = 1.52, 95% CI .90-2.57). CONCLUSIONS: US citizens should be aware of regional variation of injury deaths in foreign countries, especially for motor vehicle crashes, drowning, and violence. Improved knowledge of regional variations of injury death and risk for travelers can further inform travelers and the development of evidence-based prevention programs and policies. The State Department Web site is a new data source that furthers our understanding of this challenging travel-related health issue.

The association of driver age with traffic injury severity in Wisconsin.

OBJECTIVES: To quantify the association of driver's age with the risk of being injured, dying, and experiencing injuries of different severity when involved in a motor vehicle crash. METHODS: Data from the Wisconsin Crash Outcome Data Evaluation System (CODES) from 2002 to 2004 were used to study 602,964 drivers of a car or truck who were involved in a motor vehicle crash. Odds ratios (OR) or relative risk ratios (RRR) and their 95 percent confidence intervals (CIs) were calculated for age groups, in relation to the outcomes of injury, fatality, and injury severity using logistic regression models, which controlled for sex, alcohol use, urban/rural location, seat belt use, ejection, airbag deployment, vehicle type, and highway class. RESULTS: Increasing age was strongly associated the risk of dying or experiencing severe injuries for drivers involved in motor vehicle crashes with the greatest risk in drivers 85 years and older. Compared to drivers aged 25-44, drivers 85 years and older had the highest risks for moderate injury (ISS = 9-15; RRR = 5.44, 95% CI: 3.97-7.47), severe injury (ISS = 16-74; (RRR = 4.32, 95% CI: 2.73-6.84), and fatality (OR = 10.93, 95% CI: 7.76-15.38). In contrast, drivers 85 years and older had no increase in risk for minor injury (ISS = 1-8; OR = 0.94, 95% CI: 0.84-1.05). CONCLUSIONS: The oldest drivers involved in motor vehicle crashes had the highest risk for severe injury and fatality. In light of the increasing number of the oldest drivers and their poor outcomes from severe trauma, substantial morbidity can be expected to occur in the oldest drivers. Evidence-based measures to reduce the risks to older drivers should continue to be developed, evaluated, and implemented.

The burden of suicide in Wisconsin's older adult population.

INTRODUCTION: Suicide rates in the older adult population are disproportionately high, yet most studies focus on youth suicide. This study characterized risk factors for elder suicide in Wisconsin. METHODS: Wisconsin residents aged > or =65 who committed suicide from 2001-2006 were identified using the Violent Injury Reporting System (VIRS; 2001-2003) and the Wisconsin Violent Death Reporting System (WVDRS; 2004-2006). Multivariate regression was used to determine the risk of suicide and to adjust crude rates. Suicide circumstances and methods were also examined. RESULTS: From 2001-2006, the rate of suicide of those > or =65 was 12.4 per 100,000 per year, lower than the national average of 14.7 per 100,000. Multivariate analysis in Caucasians found that compared to married individuals, those widowed, divorced, or never married had a 2.5- to nearly 5-fold increase in risk of suicide death. Males aged 65-74 had almost a 7-fold increased risk compared to females of that age, and the risk increased for males as they aged, compared to females 65-74 years old. Almost 40% of the cases had a medical examiner or coroner report that the victim had a diagnosed mental illness. Forty-two percent of victims had documented alcohol toxicology screening; of these, 16% were positive for alcohol at the time of death. The most common method of suicide was firearm use (66.9%). DISCUSSION: Being single, male, and a male advancing in age are risk factors of suicide in the elderly. Health care workers, community advocates, and public health workers should be cognizant of these risk factors to facilitate early recognition and intervention.

Before and after the trauma bay: the prevention of violent injury among youth.

Despite a decline in the incidence of homicide in recent years, the United States retains the highest youth homicide rate among the 26 wealthiest nations. Homicide is the second leading cause of death overall and the leading cause of death for male blacks aged 15 to 24 years. High rates of health care recidivism for violent injury, along with increasing research that demonstrates the effectiveness of violence prevention strategies in other arenas, dictate that physicians recognize violence as a complex preventable health problem and implement violence prevention activities into current practice rather than relegating violence prevention to the criminal justice arena. The emergency department (ED) and trauma center settings in many ways are uniquely positioned for this role. Exposure to firearm violence doubles the probability that a youth will commit violence within 2 years, and research shows that retaliatory injury risk among violent youth victims is 88 times higher than among those who were never exposed to violence. This article reviews the potential role of the ED in the prevention of youth violence, as well as the growing number of ED- and hospital-based violence prevention programs already in place.

Injury reporting on local TV news: a prime-time opportunity for prevention.

BACKGROUND: Local television news is America's primary source of information and may be an opportunity to shape public opinion surrounding issues such as injury prevention. OBJECTIVE: This study sought to systematically evaluate unintentional-injury coverage on local television news and to identify frequently interviewed public-service professionals and factors associated with discussion of risk factors and prevention. METHODS: Late news broadcasts from 122 local television stations within the U.S. during October 2002 were analyzed. The main outcomes variables were counts of case-injury stories: motor-vehicle crashes, fires, falls, drowning, poisonings, and sports-recreational injuries; identification of interviewed public service professionals; and discussion of risk factors and prevention. Bivariate and mulitvariate analysis was performed to identify predictors of discussion of prevention measures, risk factors, or both. Data were analyzed in Fall 2006. RESULTS: From 2795 broadcasts, 1748 case-injury stories were identified. Fires and motor-vehicle crashes constituted 84% of the case-injury stories. There were 245 case-injury stories containing an interview with a public service professional. Police officers and firefighters accounted for 82% of these interviews. Interviews with police officers and firefighters were independently associated with discussion of risk factors and prevention measures for motor-vehicle crashes (OR=2.49, CI=1.7-3.6) and fires (OR=2.77, CI=1.2-5.9), respectively. CONCLUSIONS: Motor-vehicle crashes and fires were the most commonly reported injury topics. Police officers and firefighters were most commonly interviewed and, if interviewed, increased the likelihood that risk factors, prevention measures, or both were discussed. Optimizing the messages delivered by public service professionals through public service professional-level and media-level interventions may be an opportunity for disseminating injury-prevention information to the public and to policymakers, and methods to increase the likelihood of media interviews with public service professionals should be explored.

Fatal injuries of US citizens abroad.

BACKGROUND: US citizens are increasingly traveling, working, and studying abroad as well as retiring abroad. The objective of this study was to describe the type and scope of injury deaths among US citizens abroad and to compare injury death proportions by region to those in the United States. METHODS: A cross-sectional design using reports of US citizen deaths abroad for 1998, 2000, and 2002 on file at the US State Department was employed. The main outcome measures were the frequencies of injury deaths and proportional mortality ratios (PMRs) comparing deaths abroad to deaths in the United States. RESULTS: Two thousand eleven injury deaths were reported in the 3 years, comprising 13% of all deaths. The overall age-adjusted PMR for injury fatalities abroad compared to the United States was 1.6 (95% confidence interval 1.6-1.7). The highest age-adjusted PMRs for motor vehicle crashes were found in Africa (2.7) and Southeast Asia (1.6). The proportion of drowning deaths was elevated in all regions abroad. CONCLUSIONS: Injuries occur at a higher proportion abroad than in the United States. Motor vehicle crash and drowning fatalities are of particular concern. Improved data quality and surveillance of deaths would help government agencies create more evidence-based country advisories.

Competency-based strategies for injury control and prevention curriculums in undergraduate medical education.

Injury, including unintentional injury and intentional injury, is the leading cause of death in people aged