Global Mortality From Firearms, 1990-2016

Firearm injury to the left buttock with uterus penetrating trauma

A multispecialty trauma team must provide care for pelvic gunshot wounds (PGW) due to the high risk of associated morbidity and mortality, the high density of organs that might be wounded within the pelvis, and the potential consequences of these complicated injuries. We present a case of a 59-year-old woman hemodynamically stable with firearm injury to the left buttock. CT examination showed free air in the peritoneal cavity and in the retroperitoneum and a focal contrast extravasation within the uterine fundus. The patient underwent urgent laparotomy that revealed triple bowel perforation (sigmoid colon, medium rectum, ileum) and a laceration of the posterior and anterior uterine wall at level of the cervix with no signs of active bleeding. The bullet was lodged above the peritoneal reflection, in the right pelvis, and it was removed, and handed over to the judicial authority. The perforated bowel segments were resected with Hartmann's procedure and ileal anastomosis. The uterine laceration was repaired. Although all the viscera and the structures along the trajectory can be harmed, pelvic gunshot wounds have the potential to inflict serious injury. Nongravid uterine traumas are a unique occurrence, and proper care requires an understanding of lesion grading. Finding the gynecological lesion in female patients is essential to receiving the best care and protecting the reproductive system.

Epidemiology of civilian's gunshot wound injuries admitted to intensive care unit: A retrospective, multi-center study

BACKGROUND

Few studies investigated the outcome of patients admitted to intensive care unit (ICU) for gunshot wounds (GSW). The purpose of this study was to determine the 28-day mortality, and to analyze the impact of variables on the mortality of patients admitted to ICU with GSW in four French University Hospitals level-1 regional trauma centers.

METHOD

All medical files of adult patients (above fifteen years old) admitted to four French University Hospitals level-1 regional trauma centers for GSW were retrospectively analyzed from January 1st 2015 to June 30th 2021. The primary aim was to determine 28-day death rate of patients admitted in ICU for GSW. The secondary aim was to describe biological parameters, injuries and management of patients admitted to our ICUs, and to identify the variables associated with the 28-day mortality rate. A multivariate analysis allowed determining independent mortality factors. A Kaplan-Meier analysis compared mortality according to head injury.

RESULTS

Among 17,262 patients screened, 173 (1 %) were admitted for GSW and 162 were analyzed. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h after ICU admission, and 87.5 % of deaths within three days of ICU admission. The 28-day death rate of patients with head injury was significantly higher as compared to patients without head injury (p < 0.001). Out of forty deaths, twenty-three (57.5 %) were due to head injury, and nine (22.5 %) were due to bleeding. The mechanisms were assault (45.1 %), suicide (34.6 %), accident (4.9 %) and unidentified (15.4 %). In a multivariate analysis, variables associated with the 28-day death rate were age, pre-hospital Glasgow coma score, and Injury Severity Score.

CONCLUSION

GSW represented 1 % of ICU admission. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h due to head injuries and bleeding. Head injuries were associated with significantly higher mortality rate.

Temporal trends in female firearm homicides across states in the Northeast of Brazil during the period 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.

study

BACKGROUND

Mexico is among the countries with the highest mortality rates by firearms worldwide. We aimed to analyse the trend in the burden of firearm violence (FV) by age and sex in Mexico at a national and subnational level, and the association between this burden and the Sociodemographic Index.

METHODS

We used estimates from the Global Burden of Disease (GBD)-2019 study for the analysis of FV mortality, premature mortality and disability for all available age-groups and by sex. The GBD data separates FV into three categories-interpersonal violence from firearms, unintentional injuries from firearms and self-harm from firearms. We used a joinpoint regression analysis to analyse the temporal trends of the FV burden.

RESULTS

FV exhibited a non-significant increase. By cause, there was a significant increase in the burden of interpersonal violence from firearms, a non-significant decrease in the burden of self-harm from firearms and a significant decrease in the burden of unintentional injuries from firearms. Most of the FV burden is attributed to interpersonal violence from firearms. Almost the entirety of the burden of FV results from premature mortality. The incidence of FV disability adjusted life years (DALYs) was significantly higher among males than females, and was most concentrated in males aged 20-44 and females aged 15-49. Significant heterogeneity in FV DALY trends was observed at the subnational level.

CONCLUSION

These results may help to better understand the burden of FV and help the design and implementation of national and local preventive policies.

Federal Firearm Licensee Rates and Suicide in Maryland, 2014 to 2019

INTRODUCTION

Federal firearm licensee density is associated with interpersonal firearm violence. Yet the role of Federal firearm licensees in firearm suicide remains understudied, even though firearms are the method used in more than half of suicides. This study tested associations between the spatial distribution of federal firearm licensees and firearm suicides in Maryland.

METHODS

Kernel density estimation measured federal firearm licensee and suicide rates at the census tract level (n=1,397), and SaTScan detected clusters of licensees and suicides. Choropleth maps compared visual associations between federal firearm licensee, firearm, and non-firearm suicide rates and clusters. Generalized estimating equations tested associations between Federal firearm licensee rates and clusters and the odds of using a firearm as the lethal means overall and after stratifying by biological sex. Data were obtained in 2020 and analyzed in 2020-2024.

RESULTS

The federal firearm licensee rate was associated with greater odds of firearm suicide overall (aOR=1.29, 95% CI=1.21, 1.38, p<0.001), for men (aOR=1.29, 95% CI=1.20, 1.39, p<0.001), and for women (aOR=1.26, 95% CI=1.07, 1.49, p=0.007). Suicide decedents in a census tract located in a federal firearm licensee cluster (vs not) had higher odds of firearm use overall (aOR=1.70, 95% CI=1.28, 2.27, p<0.001) and for men (aOR=1.67, 95% CI=1.22, 2.27, p=0.001), but not for women (aOR=1.65, 95% CI=0.81, 3.34, p=0.168).

CONCLUSIONS

The federal firearm licensee rate and clusters were associated with firearm suicides and unrelated to the spatial distribution of non-firearm suicides. Prevention approaches that limit the number of these federal firearm licensees or alter their sales practices, such as federal firearm licensee zoning and land use provisions, advertising restrictions, or gun shop projects, may prevent firearm suicides.

Firearm Fatalities in the Pediatric Population: A Retrospective Study From the Cook County Medical Examiner's Office

ABSTRACT

Gunshot injuries are one of the leading causes of death from trauma in the United States. In recent years, the US has experienced an increasing number of fatal pediatric cases related to firearms.A search of the database of the Cook County Medical Examiner's Office over the period January 2016-December 2021 revealed 418 deaths by gunshot wounds (GSWs) among people aged between 0 and 18 years old. Subjects were subcategorized in infants (0 to 1 year), toddlers (≥1 to 3 years), preschool (≥3 to 6 years), preadolescents (≥6 to 12 years), and adolescents (≥12 to 18 years).Most victims were males (n = 374) and adolescents (357 males and 30 females). Homicide (n = 373) was the most common manner of death. Only 2 deaths were accidental. Single GSWs deaths (n = 232) were more common than multiple GSWs (n = 186) and preferentially directed to the head in both homicides and suicides. Gang or robbery related events in areas of readily available firearms explained 4.5% of homicides (17 out of 373 cases). Among deaths by self-inflicted GSWs (n = 36), 7 cases were linked to psychiatric disorders, 3 to family difficulties, 2 to history of playing Russian roulette, and 2 to bullying at school.Pediatric gunshot injuries and deaths are an important public health problem. Understanding and addressing individual and societal risk factors should be the first step toward prevention.

Fallacy of attributing the U.S. firearm mortality epidemic to mental health

BACKGROUND

Annual global data on mental disorders prevalence and firearm death rates for 2000-2019, enables the U.S. to be compared with comparable counties for these metrics.

METHODS

The Institute for Health Metrics and Evaluation (IHME) Global Health Burden data were used to compare the prevalence of mental disorders with overall, homicide and suicide firearm death rates including homicides and suicides, in high sociodemographic (SDI) countries.

RESULTS

Overall and in none of the nine major categories of mental disorders did the U.S. have a statistically-significant higher rate than any of 40 other high SDI countries during 2019, the last year of available data. During the same year, the U.S. had a statistically-significant higher rate of all deaths, homicides, and suicides by firearm (all p<<0.001) than all other 40 high SDI countries. Suicides accounted for most of the firearm death rate differences between the U.S. and other high SDI countries, and yet the prevalence of mental health disorders associated with suicide were not significantly difference between the U.S. and other high SDI countries.

CONCLUSION

Mental disorder prevalence in the U.S. is similar in all major categories to its 40 comparable sociodemographic countries, including mental health disorders primarily associated with suicide. It cannot therefore explain the country's strikingly higher firearm death rate, including suicide. Reducing firearm prevalence, which is correlated with the country's firearm death rate, is a logical solution that has been applied by other countries.

The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries

PURPOSE

This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management.

METHODS

We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated.

RESULTS

The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews.

CONCLUSIONS

Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes.

LEVEL OF EVIDENCE

Level III, Diagnostic Study.

Intimate partner femicide (IPF): Medico-legal investigation at the Institutes of Legal Medicine of Freiburg (Germany) and Padova (Italy)

Violence against women is a significant public health concern, with femicide as its most extreme manifestation. This crime is often perpetrated by current or former intimate partners, thus taking the name of intimate partner femicide (IPF). Although international comparisons are essential for prevention policies, cross-country comparative studies are scarce in this context. The aim of this study was to evaluate and compare clinical, epidemiological and medico-legal characteristics of IPF autopsy cases investigated at the Institutes of Legal Medicine of two Western European cities, in order to identify a potential medico-legal pattern of IPF. Autopsy and police reports of IPF cases occurred in the judicial district of Freiburg (Germany) and Padova (Italy) from 2000 to 2022 were analyzed. Data relating to victims, perpetrators, relationship context, and circumstantial and pathological-forensic characteristics of the homicide were collected. Statistical analyses were performed to explore potential relationships between the data collected. Additionally, a review of the literature dealing with autopsy-based studies on IPF was performed. Overall, 82 cases of IPF were analyzed, 39 from Freiburg and 43 from Padova. A total of 6 papers fulfilled the review inclusion criteria. Our study identified a medico-legal pattern of IPF and demonstrated that it did not vary substantially between the two European Countries considered, suggesting that certain IPF characteristics are shared at the European level. However, a significant finding emerged regarding the higher prevalence of firearm-related IPFs in Italy compared to Germany. Forensic pathology research might contribute to developing targeted prevention policies to protect women from this lethal form of violence.

A decade of firearm injuries: Have we improved?

BACKGROUND

Firearm injuries are a growing public health issue, with marked increases coinciding with the coronavirus disease 2019 (COVID-19) pandemic. This study evaluates temporal trends over the past decade, hypothesizing that despite a growing number of injuries, mortality would be unaffected. In addition, the study characterizes the types of centers affected disproportionately by the reported firearm injury surge in 2020.

METHODS

Patients 18 years and older with firearm injuries from 2011 to 2020 were identified retrospectively using the National Trauma Data Bank (NTDB®). Trauma centers not operating for the entirety of the study period were excluded to allow for temporal comparisons. Joinpoint regression and risk-standardized mortality ratios (SMR) were used to evaluate injury counts and adjusted mortality over time. Subgroup analysis was performed to describe centers with the largest increases in firearm injuries in 2020.

RESULTS

A total of 238,674 patients, treated at 420 unique trauma centers, met inclusion criteria. Firearm injuries increased by 31.1% in 2020, compared to an annual percent change of 2.4% from 2011 to 2019 ( p = 0.01). Subset analysis of centers with the largest changes in firearm injuries in 2020 found that they were more often Level I centers, with higher historic trauma volumes and percentages of firearm injuries ( p < 0.001). Unadjusted mortality decreased by 0.9% from 2011 to 2020, but after controlling for demographics, injury characteristics and physiology, there was no difference in adjusted mortality over the same time period. However, among patients with injury severity scores ≥25, adjusted mortality improved compared with 2011 (SMR of 0.950 in 2020; 95% confidence interval, 0.916-0.986).

CONCLUSION

Firearm injuries pose an increasing burden to trauma systems, with Level I and high-volume centers seeing the largest growth in 2020. Despite increasing numbers of firearm injuries, mortality has remained unchanged over the past decade.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Long gun violence in California versus Texas: How legislation can reduce firearm violence

Introduction

Long guns (LGs) are uniquely implicated in firearm violence and mass shootings. On 1/1/2019 California (CA) raised the minimum age to purchase LGs from 18 to 21. This study aimed to evaluate the incidence of LG violence in CA vs. Texas (TX), a state with rising firearm usage and fewer LG regulations, hypothesizing decreased LG firearm incidents in CA vs increased rates in TX after CA LG legislation.

Methods

A retrospective analysis of the Gun Violence Archive (2015-2021) was performed. An additional analysis of all firearm incidents within TX and CA was performed. CA and TX census data were used to calculate incidents of LG violence per 10,000,000 people. The primary outcome was the number of LG-related firearm incidents. Median yearly rates of LG violence per 10,000,000 people were compared for pre (2015-2018) vs post (2019-2021) CA LG legislation (Senate Bill 1100 (SB1100).

Results

Median LG incidents decreased in CA post-SB1100 (4.21 vs 1.52, p < 0.001) by nearly 64 %, whereas any gun firearm violence was similar pre vs post-SB1100 (77.0 vs 74.5 median incidents, p = 0.89). In contrast, median LG incidents increased after SB1100 (4.34 vs 5.17 median incidents, p = 0.011) by nearly 35 % in TX, with any gun incidents increasing by nearly 53 % (83.48 vs 127.46, p < 0.001).

Conclusion

CA LG firearm incidents decreased following SB 1100 legislation whereas the incidence in TX increased during this same time. Meanwhile, the incidence of any firearm violence remained similar in CA but increased in TX. This suggests the sharp decline in CA LG incidents may be related to SB1100. Accordingly, increasing the age to purchase a LG from 18 to 21 at a federal level may help curtail LG violence nationally.

Crossbow Injuries: Predictors of Mortality

INTRODUCTION

Crossbow injuries are rare but carry significant morbidity and mortality, and there is limited evidence in the medical literature to guide care. This paper reviews the case reports and case series of crossbow injuries and looks for trends regarding morbidity and mortality based on the type of arrow, anatomic location of injury, and intent of injury.

METHODS

Multiple databases were searched for cases of crossbow injuries and data were abstracted into a spreadsheet. Statistics were done in SPSS.

RESULTS

358 manuscripts were returned in the search. After deduplication and removal of nonclinical articles, 101 manuscripts remained. Seventy-one articles describing 90 incidents met the inclusion criteria. The mean age was 36.5 years. There were 10 female and 79 male victims. Fatality was 36% for injuries by field tip arrows and 71% for broadhead arrows, p  =  .024. Assaults were fatal in 84% of cases, suicides in 29%, and accidental injuries in 17%, p < .001. Mortality was similar for wounds to the head and neck (41%), chest (42%), abdomen (33%), extremities (50%), and multiple regions, p  =  .618.

CONCLUSIONS

Crossbows are potentially lethal weapons sold with fewer restrictions than firearms. Injuries caused by broadhead arrows are more likely to be fatal than injuries from field tip arrows. The anatomic location of injury does not correlate with fatality. More than half of crossbow injuries are due to attempted suicide, with a high case-fatality rate.

Burden and Regional Disparities in the Firearm Mortality Profiles in Brazil: A Systematic Analysis of Findings From the Global Burden of Disease 2019

Introduction

Owing to legislative changes and regional disparities, knowledge of firearm death profile in Brazil is limited, creating a complex situation that requires data to improve the strategies to reduce the burden of this health problem. The aim of this study was to describe the burden of firearm injuries and regional disparities in Brazil, including the characterization of mortality profiles specifically in the year 2019.

Method

The researchers extracted secondary data from the Institute of Health Metrics and Evaluation, from Global Burden of Disease study, including information on new cases and deaths caused by firearms. They also examined metrics such as incidence, mortality, years of life lost owing to disability, years of life living with disability, and years of life lost owing to premature death. Descriptive statistics (number of deaths and proportion) were performed.

Results

The findings reveal that nearly 50,000 firearm-related deaths occurred in Brazil in 2019, corresponding to a rate of 21.6 deaths per 100,000 inhabitants. These deaths collectively contributed to around 3 million years of life lost when adjusted for disability. Notably, there are significant regional disparities, with the Northeast region of Brazil bearing a higher burden of firearm injuries. The study further differentiates mortality profiles on the basis of the type of firearm-related death. Young individuals and young adults experience a higher mortality rate due to homicides. On the other hand, individuals aged ≥70 years are more prone to firearm-related suicides.

Conclusions

Firearm injuries in Brazil have distinct mortality profiles. Acknowledging these different profiles is crucial when devising effective public policies to address this issue.

Empowering Victims of Lived Violence: Delaware's Hospital Violence Intervention Program (HVIP)

Hospital Violence Intervention Programs (HVIP) are increasingly implemented across a variety of healthcare-associated contexts to prevent and address violent intentional injury. We describe the establishment of a health system funded HVIP in Delaware and the direct experiences of staff and violence-specialized Community Health Workers.

Intentional child and adolescent homicides in Milan (Italy): A 30-year interdisciplinary study

This study aims to discuss the forensic and criminological implications of child homicides in the territory of Milan, Italy. The authors present a retrospective study on all the cases of child and adolescent homicides, that were observed at the Institute of Legal Medicine of Milan (Italy) in the last 30 years (from January 1991 to December 2020). A total of 46 child homicides were collected, focusing on the sociological features, by highlighting peculiar cases, risk factors, potential changing social trends, and comparing our cases with the current literature. The analysis revealed a statistically significant relationship (p < 0.05) for male adolescents and indicated that adolescent homicides were more frequently perpetrated in extrafamilial contexts. In contrast, neonaticides and infanticides were mainly committed at home. Furthermore, the Fisher's Exact test revealed that child murders were mainly committed by immigrants in the Milan district after 2005 (p < 0.05). The two main causes of death were due to sharp and firearm injuries. While the relationship between homicide clusters and homicides committed by sharp objects was not significant, adolescent homicides were mainly committed using firearms (p < 0.05). The present study may help to identify risk factors for homicides against child and adolescent. Consequently, policies that identify, prevent, and minimize this extreme violence should be designed to interrupt the vicious circle of such dreadful murderous events. Child and adolescent homicides deserve additional focus and better education for healthcare professionals and further research should be carried out to develop therapeutic and caring strategies.

Beneficial Effects of Human Schwann Cell-Derived Exosomes in Mitigating Secondary Damage After Penetrating Ballistic-Like Brain Injury

There is a growing body of evidence that the delivery of cell-derived exosomes normally involved in intracellular communication can reduce secondary injury mechanisms after brain and spinal cord injury and improve outcomes. Exosomes are nanometer-sized vesicles that are released by Schwann cells and may have neuroprotective effects by reducing post-traumatic inflammatory processes as well as promoting tissue healing and functional recovery. The purpose of this study was to evaluate the beneficial effects of human Schwann-cell exosomes (hSC-Exos) in a severe model of penetrating ballistic-like brain injury (PBBI) in rats and investigate effects on multiple outcomes. Human Schwann cell processing protocols followed Current Good Manufacturing Practices (cGMP) with exosome extraction and purification steps approved by the Food and Drug Administration for an expanded access single ALS patient Investigational New Drug. Anesthetized male Sprague-Dawley rats (280-350g) underwent PBBI surgery or Sham procedures and, starting 30 min after injury, received either a dose of hSC-Exos or phosphate-buffered saline through the jugular vein. At 48h after PBBI, flow cytometry analysis of cortical tissue revealed that hSC-Exos administration reduced the number of activated microglia and levels of caspase-1, a marker of inflammasome activation. Neuropathological analysis at 21 days showed that hSC-Exos treatment after PBBI significantly reduced overall contusion volume and decreased the frequency of Iba-1 positive activated and amoeboid microglia by immunocytochemical analysis. This study revealed that the systemic administration of hSC-Exos is neuroprotective in a model of severe TBI and reduces secondary inflammatory injury mechanisms and histopathological damage. The administration of hSC-Exos represents a clinically relevant cell-based therapy to limit the detrimental effects of neurotrauma or other progressive neurological injuries by impacting multiple pathophysiological events and promoting neurological recovery.

Depictions of Firearms and Other Projectile Weapons in Top-Selling Japanese Manga

Firearm violence is a pressing public health issue in the United States and becoming increasingly so worldwide. This concern has prompted researchers to examine the prevalence of such violence in media entertainment. Japanese manga have a large youth readership in the U.S., yet research on their depictions of firearms is presently lacking. We randomly selected 50 chapters from each of ten top-selling manga series worldwide (N = 500) to identify dialogue, action, and other illustrations involving handguns, rifles, machine guns, other projectile weapons, and bombs. Of the 500 chapters, 129 (25.8%) had at least one depiction of a firearm or other projectile weapon, with 684 instances of characters handling (e.g., carrying, holding, firing, reloading) such a weapon. Of the 384 unique characters so depicted, the vast majority were males (88.3%), adults (92.2%), and "good" characters (73.4%). Manga readers, especially male adolescents and preteens, are frequently exposed to storylines in which one or more characters are using a firearm or other projectile weapon. Working collaboratively, manga publishers and distributors should act to develop and implement a comprehensive rating system to flag content that may be harmful to youth so that parents can more easily monitor what their children are reading.

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.

Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials

Injury mechanism is an important consideration when conducting clinical trials in trauma. Mechanisms of injury may be associated with differences in mortality risk and immune response to injury, impacting the potential success of the trial. We sought to characterize clinical and endothelial cell damage marker differences across blunt and penetrating injured patients enrolled in three large, prehospital randomized trials which focused on hemorrhagic shock. In this secondary analysis, patients with systolic blood pressure < 70 or systolic blood pressure < 90 and heart rate > 108 were included. In addition, patients with both blunt and penetrating injuries were excluded. The primary outcome was 30-day mortality. Mortality was characterized using Kaplan-Meier and Cox proportional-hazards models. Generalized linear models were used to compare biomarkers. Chi squared tests and Wilcoxon rank-sum were used to compare secondary outcomes. We characterized data of 696 enrolled patients that met all secondary analysis inclusion criteria. Blunt injured patients had significantly greater 24-h (18.6% vs. 10.7%, log rank p = 0.048) and 30-day mortality rates (29.7% vs. 14.0%, log rank p = 0.001) relative to penetrating injured patients with a different time course. After adjusting for confounders, blunt mechanism of injury was independently predictive of mortality at 30-days (HR 1.84, 95% CI 1.06-3.20, p = 0.029), but not 24-h (HR 1.65, 95% CI 0.86-3.18, p = 0.133). Elevated admission levels of endothelial cell damage markers, VEGF, syndecan-1, TM, S100A10, suPAR and HcDNA were associated with blunt mechanism of injury. Although there was no difference in multiple organ failure (MOF) rates across injury mechanism (48.4% vs. 42.98%, p = 0.275), blunt injured patients had higher Denver MOF score (p < 0.01). The significant increase in 30-day mortality and endothelial cell damage markers in blunt injury relative to penetrating injured patients highlights the importance of considering mechanism of injury within the inclusion and exclusion criteria of future clinical trials.

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.

Community support for injured patients: A scoping review and narrative synthesis

BACKGROUND

Community-based peer support (CBPS) groups have been effective in facilitating access to and retention in the healthcare system for patients with HIV/AIDS, cancer, diabetes, and other communicable and non-communicable diseases. Given the high incidence of morbidity that results from traumatic injuries, and the barriers to reaching and accessing care for injured patients, community-based support groups may prove to be similarly effective in this population.

OBJECTIVES

The objective of this review is to identify the extent and impact of CBPS for injured patients.

ELIGIBILITY

We included primary research on studies that evaluated peer-support groups that were solely based in the community. Hospital-based or healthcare-professional led groups were excluded.

EVIDENCE

Sources were identified from a systematic search of Medline / PubMed, CINAHL, and Web of Science Core Collection.

CHARTING METHODS

We utilized a narrative synthesis approach to data analysis.

RESULTS

4,989 references were retrieved; 25 were included in final data extraction. There was a variety of methodologies represented and the groups included patients with spinal cord injury (N = 2), traumatic brain or head injury (N = 7), burns (N = 4), intimate partner violence (IPV) (N = 5), mixed injuries (N = 5), torture (N = 1), and brachial plexus injury (N = 1). Multiple benefits were reported by support group participants; categorized as social, emotional, logistical, or educational benefits.

CONCLUSIONS

Community-based peer support groups can provide education, community, and may have implications for retention in care for injured patients.

Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019

PURPOSE

Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality.

METHOD

Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index.

RESULTS

One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings.

DISCUSSION

Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Shelter in Place and an Alarming Increase in Penetrating Trauma in Children and Concerning Decrease in Child Abuse

BACKGROUND

On March 14, 2020, schools across North Carolina (NC) closed in response to Covid-19, forcing completion of the school year at home. Most pediatric trauma occurs at home with a higher prevalence when children are out of school. We queried the state trauma database to assess if the 2020 "shelter in place" was associated with an increase in pediatric trauma statewide.

METHODS

The NC trauma database was queried for injuries in children (age < 18 yrs) from 13 March-1 August 2020, and the corresponding months of 2018 and 2019. The number and type of injuries were compared. We also queried the NC death certificate and child welfare databases. Data were analyzed by standard statistical methods using chi-squared or Kruskal-Wallis test.

RESULTS

Total pediatric trauma cases were lower during 2020 (71.6 per 100,000) compared to 2018 (92.4 per 100,000) and 2019 (80 per 100,000) (P < .001); however, average injury severity score (ISS) was higher (P = .001). A significant increase in firearm injuries were seen in 2020 (P = .016), with an increase in mortality (P = .08) and ISS (P = .013). The rate of child abuse trauma decreased in 2020 (P = .005) as did the number of child abuse and neglect reports (P < .001). There were also significant decreases in trauma due to sports, burns, falls, and motor vehicle accidents.

CONCLUSION

While overall pediatric trauma decreased during the Covid-19 pandemic, there was an alarming increase in penetrating injuries in children. Child abuse trauma and reports decreased, which is concerning for lower identification of abuse.

The Oregon District Shooting: Reviewing the Pre-Hospital Protocols and the Role of the Resident During a Multiple Casualty Event

Background: Review of multiple casualty events (MCEs) protocols in an academic trauma center and more importantly role of residents in management of MCEs has not been discussed. Also, no real-world examples have been described. This study reviews utilization of multiple casualty protocols by the area hospitals and EMS along with role of residents in one such real-world MCEMethods: A mass shooting event in the Oregon District in Dayton, Ohio from 2019 was reviewed. MCE protocols from a Level I trauma center were reviewed as well as patient outcomes and role of residents.Results: A total of 10 casualties were observed and 38 patients presented to hospitals throughout the city. There were 25 patients presented to the Level I trauma center, 1 to the Level II trauma center, and 12 to the Level III trauma centers in the community. Surgical and Emergency residents performed initial triage upon arrival to the ED, managed resuscitation, and performed various procedures under supervision of attending staff. A total of 5 patients required emergent surgery and 4 patients required tourniquets. All patients that were presented to the hospitals survived.Conclusion: MCEs are going to continue, and healthcare systems should have protocols in place. Residents are a valuable resource to hospital systems that provide trauma services. Creation of a protocol with the assistance of EMS will allow first responders to utilize resources available. We recommend testing of this protocol, as an MCE in your area may not be a matter of if, but when.

Factors affecting return to work time and functional outcome after low-velocity gunshot injuries related to foot in civilian population

BACKGROUND

Purpose of this study was to identify factors affecting return to work time and functional outcomes after low-velocity gunshot injuries related to foot. Related complications are also analyzed.

METHOD

This study conducted as retrospective cohort study in tertiary care university hospital. Data on 26 patients obtained through retrospective database search. Type of causing weapon, anatomic location of wound, wound type according to Gustilo Anderson classification, extend of damage regarding injured structures, extend of soft tissue damage, duration of hospital stay, need of reconstructive surgery, return-to-work time, follow-up period and functional scores at final follow-up were recorded. Factors affecting functional outcome and return-to-work time were analyzed.

RESULTS

Total of 12 patients (46.2 %) experienced complications, with eight being deep soft tissue infections. The mean MFS score for the study group was 77.27 (±11.82). The mean MFS for the pistol group was 83.46 (±6.90), extent of soft tissue damage was an independent risk factor (OR 10.67, 95 % CI 1.70-66.72, p = 0.011) for poor outcomes. On average, patients took 10.12 months (±7.59) to return to work, the type of gun used was an independent variable associated with delayed return to work (OR 144, 95 % CI 8.04-2578.09, p = 0.011).

CONCLUSION

Gunshot injuries related to foot can lead to a high rate of complications, loss of workdays, and permanent functional losses. Therefore, it is crucial to develop appropriate treatment plans and manage inevitable complications in these injuries.

LEVEL OF EVIDENCE

Level IV, Case series.

Firearm-related suicides, homicides, and homicide-suicides involving security officers in two East African Countries: a press media review

BACKGROUND

Firearm violence is a growing public health problem causing death globally. With easy accessibility to firearms, suicides, homicides, and homicide-suicides have increased among security officers, especially in developing countries affected by long-standing civil wars/political insurgencies. No study has explored firearm violence in East African countries. This study describes the press media reporting of suicides, homicides, and homicide-suicides among security officers in two East African countries (Uganda and Kenya).

METHODS

Due to the absence of suicide databases among East African countries, the present study reviewed press media reports. We utilized content analysis of suicides, homicides, and homicide-suicides reports among security forces. Relevant media reports between January-2020 and May-2023 were searched. Using ANOVA and chi-square tests, we tested for statistical differences in characteristics between victims and perpetrators.

RESULTS

Among the 56 perpetrated reports, most of them were homicides 44.64% (n = 25/56), 30.36% (n = 17/56) were homicide-suicides, and 25% (n = 14/56) were suicides. Perpetrators' age ranged from 21 to 47 years, majority being males [53/56 (94.64%)]. Victims were 58, mostly Ugandans [41/58 (73.21%)] with a mean age of 33.5 ± 8.81 years. Among the three main outcomes, statistically significant difference existed by country (χ2 = 23.88, p < 0.001), and perpetrators' age (F = 8.59, p = 0.005). There was a significant difference between perpetrators and the number of victims lost by age of victims (F = 10.37, p = 0.002). Among victims, type of security of perpetrator and citizenship of victims (χ2 = 24.18, p < 0.001) showed statistical difference with Ugandans having more victims to army officers while Kenyans to police officers. Brief incident descriptions pointed towards relationship dysfunctions, alcohol/substance abuse, intentional harm, and financial disagreements, as the potential causes. Only two perpetrators were reported to have mental health-related conditions.

CONCLUSION

This study shows that media reported firearms-related suicides, homicides, and homicide-suicides among security forces commonly involve males. Perpetrators in Uganda are mainly army officers while in Kenya the perpetrators are mostly police officers. Mental health conditions were not frequently reported among perpetrators. We recommend strengthening and enforcing gun regulation policies among security officers to curb this growing problem in these countries. Routine screening of mental health problems to enable early interventions is recommended among security officers.

Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn

Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..

Bullet Fragment Retrieval During Intramedullary Nailing: A Report of 2 Cases

CASE

Two young adult patients, 22 and 27 years, who sustained ballistic long bone fractures, presented for incarcerated, retained metallic fragments in the medullary canal, which blocked fixation. Owing to the presence and location of the fragments, each case required a bullectomy (removal of the metallic fragment) before intramedullary nail fixation because the projectile impeded the appropriate insertion of the intramedullary rod and, in one case, induced fracture malalignment. Attempts at removal using conventional tools did not provide adequate length or grasp of the retained projectile, necessitating the use of the novel technique. The Babcock Laparoscopic Endopath is an easy-to-use, ubiquitous tool that facilitates the removal of content within the intramedullary canal, including metallic or bony fragments.

CONCLUSION

There is limited literature describing accessible, cost-effective techniques for the removal of intramedullary retained metallic foreign fragments when it is unremovable through conventional means. This article reports on a novel, minimally invasive technique for bullet removal from the intramedullary canal of the femur and tibia using the Babcock Laparoscopic Endopath, a tool typically used by urologists. Both patients were followed for at least 8 weeks postoperatively with no complications secondary to the procedure. The article describes the technique and advantages of using this readily available tool that is both flexible enough to navigate through the intramedullary canals as well as rigid enough to obtain and manipulate metallic objects.

Firearm Safety and Suicide Prevention for Medically Complex Older Veterans: Perspectives of VA Home-Based Primary Care Directors and Psychologists

OBJECTIVES

Determine strategies and resources used by VA Home-Based Primary Care (HBPC) teams to discuss firearm safety and suicide risk with older veterans and their families or caregivers. Training and resource needs for promoting firearm safety with older veterans were also ascertained.

METHODS

Ten focus groups (N = 37) were conducted virtually in 2022 with HBPC directors and psychologists. Qualitative rapid response coding identified domains and themes within transcripts.

RESULTS

Analysis revealed three major domains: firearm safety, suicide risk, and resources/trainings. Firearm safety themes included discussions during clinical procedures, firearm-related challenges, veteran culture, and barriers and facilitators to effective conversations. Suicide risk themes included assessment procedures, frequency/types of risk conversations, factors related to suicidal ideation/behavior, challenges, and strategies to enhance communication. Resource/training themes included those currently used and perceived needs.

CONCLUSIONS

Participants described strategies for facilitating firearm safety and suicide prevention discussions with older veterans, their families, and caregivers. Using respectful language and attending to values related to firearm ownership were identified as essential.

CLINICAL IMPLICATIONS

Additional clinician/staff training/resources are needed for addressing older veteran firearm safety and suicide risk, including how to conduct more effective conversations with older veterans on these topics and better engage families/caregivers in prevention efforts.

State Gun Regulations and Reduced Gun Ownership are Associated with Fewer Firearm-Related Suicides Among Both Juveniles and Adults in the USA

BACKGROUND

Few studies have investigated the relationship between specific gun regulations and gun ownership with the firearm-related suicide rate among juveniles and adults across U.S. states. Therefore, this study seeks to determine if gun ownership rates and gun restrictions are related to the firearm-related suicide rate in both the pediatric and adult populations.

METHODS

Fourteen measures of state gun law restrictions and gun ownership were collected. These included Giffords Center ranking, gun ownership percentages, and 12 specific firearm laws. Unadjusted linear regressions modeled the relationship between each individual variable and the rate of firearm-related suicides for adults and children across states. This was repeated using a multivariable linear regression adjusting for poverty, poor mental health, race, gun ownership, and divorce rates by state. P values of <0.004 were considered significant.

RESULTS

In the unadjusted linear regression, 9 of 14 firearm-related measures were statistically associated with fewer firearm-related suicides in adults. Similarly, 9 of 14 measures were found to be associated with fewer firearm-related suicides in the pediatric population. In the multivariable regression, 6 of 14 vs. 5 of 14 measures were statistically associated with fewer firearm-related suicides in the adult and pediatric populations, respectively.

CONCLUSIONS

Ultimately, this study found that increased state gun restrictions and lower gun ownership rates were associated with fewer firearm related suicides among juveniles and adults in the US. This paper provides objective data to help lawmakers as they create gun control legislation that can potentially decrease the rate of fire-arm related suicide.

LEVELS OF EVIDENCE

II.

Gunshot Injury to the Face With Atypical Non-linear Bullet Trajectory: A Case Report

The disruptive effect of firearm missiles on body tissues depends on many factors. However, it mainly relates to the bullet's physical and dynamic properties and tissue-related factors. We encountered an unusual case of a gunshot injury wherein the bullet traversed the neck with an upward and non-linear trajectory with an exit from the contralateral side of the neck without damaging any vital neck organs. A 26-year-old male presented with a gunshot wound to the chin from close range. A bullet entry hole was observed on the right side of the chin, encircled by the abrasion collar, with tattoo marks around the area. The patient was conscious, with normal vital signs and no injury to the cranial nerves or aerodigestive tract. The CT imaging of the patient revealed the injury tract traversing through the muscles of the floor of the mouth to involve the left carotid and left parapharyngeal space, along with the left sternocleidomastoid muscle, with an exit hole below the left mastoid in the posterior triangle of the neck. A bullet usually travels through the body in a straight line or pathway; however, its non-linear trajectories depend on the projectile's dynamics and its interaction with the body tissues. The present case emphasizes understanding wound ballistics to know the erratic bullet trajectories in the victim's body and their interpretation, irrespective of their entry site.

Reference des cas de traumatisme par arme à feu en Afrique

BACKGROUND

In a war-torn African country, Médecins Sans Frontières supports two regional referral hospitals to address emergencies, including the treatment of firearm-related traumas. It facilitates access to healthcare and referrals, which are often hindered due to non-medical reasons.

OBJECTIVE

To determine the factors influencing the unfavourable outcome of cases referred for firearm trauma (December 2020-November 2021).

METHOD

This was a cross-sectional study using routinely collected data.

RESULTS

A total of 381 patients who were victims of firearm-related trauma were admitted, with an average age of 29 years; 28.3% had severe injuries, including thoraco-abdominal injuries and fractures. The mortality rate was 4.9%, and 7.9% left against medical advice. Patients affiliated with the irregular armed forces accounted for 45.4%, and had a two-thirds higher rate of unsuccessful referral for non-medical reasons. Patients with severe injuries at triage, affiliation with the irregular forces and being in the regular army had 2 times (P < 0.01), 5.9 times (P < 0.01) and 8.1 times (P < 0.01), respectively, a higher risk of an unfavourable outcome.

CONCLUSION

Serious cases caused by firearm injuries were more likely to have an adverse outcome. The risk was higher in those with a specific affiliation, who were more often denied access to higher referral care based on socio-political rather than medical reasons.

FOREWORD Finding Balance in the Fight Against Gun Violence

The United States is distinct among high-income countries for its problem with gun violence, with Americans 25 times more likely to be killed by gun homicide than people in other high-income countries.1 Suicides make up a majority of annual gun deaths - though that gap is closing as homicides are on the rise - and the U.S. accounts for 35% of global firearm suicides despite making up only 4% of the world's population.2 More concerning, gun deaths are only getting worse. In 2021, firearm fatalities approached 50,000, the highest we have seen in at least 40 years.3 The increase in homicides in conjunction with lower crime overall further suggests an problem specifically with guns.4 As devastating as these deaths are, it does not come close to encompassing the mass toll of America's gun violence epidemic - a toll that disproportionately impacts people of color, with the Black community suffering at the highest rates. A broader and more accurate view of what constitutes gun violence must become a part of the national discourse if we are going to develop effective strategies to combat this crisis.5.

A global perspective on gun violence injuries

INTRODUCTION AND DEFINITIONS

Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.

PRE-HOSPITAL CARE

There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.

ACUTE TREATMENT

Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.

DEFINITIVE CARE

The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.

RESOURCES AND ETHICS

There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Trauma deaths of hospitalized patients in Abu Dhabi Emirate: a retrospective descriptive study

AIM

To study the epidemiology and pattern of trauma-related deaths of hospitalized patients in Abu Dhabi Emirate, United Arab Emirates, in order to improve trauma management and injury prevention.

METHODS

The Abu Dhabi Trauma Registry prospectively collects data of all hospitalized trauma patients from seven major trauma centres in Abu Dhabi Emirate. We studied all patients who died on arrival or after admission to these hospitals from January 2014 to December 2019.

RESULTS

There were 453 deaths constituting 13.5% of all trauma deaths in the Abu Dhabi Emirate. The median (IQR) age of the patients was 33 (25-45) years, and 82% were males. 85% of the deaths occurred in the emergency department (ED) and the intensive care unit (ICU). Motor vehicle collision (63.8%) was the leading cause of death. 45.5% of the patients had head injury. Two of the seven hospitals admitted around 50% of all patients but accounted for only 25.8% of the total deaths (p < 0.001). Those who died in the ward (7%) were significantly older, median (IQR) age: of 65.5 (31.75-82.25) years, (p < 0.001), 34.4% of them were females (p = 0.09). The median (IQR) GCS of those who died in the ward was 15 (5.75-15) compared with 3 (3-3) for those who died in ED and ICU (P < 0.001).

CONCLUSIONS

Death from trauma predominantly affects young males with motor traffic collision as the leading cause. Over 85% of in-hospital deaths occur in the ICU and ED, mainly from head injuries. Injury prevention of traffic collisions through enforcement of law and improved hospital care in the ED and ICU will reduce trauma death.

Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms

Introduction

This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries.

Methods

A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020.

Results

Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001).

Conclusions

Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Radial nerve transection after ballistic humeral shaft fractures: A retrospective cohort study

INTRODUCTION

Radial nerve palsy following fracture of the humeral shaft is common. However, the incidence of nerve transection in the setting of ballistic trauma is unknown. The purpose of this study was to estimate the incidence of radial nerve transection after ballistic fracture of the humerus.

METHODS

Patients presenting to an urban, level-1 trauma center with a ballistic fracture of the humeral shaft were retrospectively reviewed. Patient demographics, clinical exam on presentation, and operative data were reviewed to determine the incidence of radial nerve palsy on initial examination, the incidence of operative treatment, the incidence of how frequently the nerve was directly visualized, and the incidence of radial nerve transection.

RESULTS

One-hundred and thirteen ballistic humeral shaft fractures were identified. Of these, 30 (26.5%) patients had a complete radial nerve palsy on exam. Of patients with a radial nerve palsy, on exam 20 were taken to the operating room and the nerve was visualized in 17 of those cases. There 2 were partially lacerated nerves and 12 nerves were completely transected. Thus, in patients with a complete nerve deficit on examination who underwent operative treatment with nerve exploration, the rate of nerve transection was 70.6%. The lower bound rate of nerve transection for all patients with radial nerve palsy (assuming all unexplored nerves were intact) was 40.0%.

CONCLUSION

The rate of nerve transection in patients with humerus shaft fractures with associated radial nerve palsies is likely higher than the rate of nerve transection in similar injuries caused by blunt mechanisms. The authors recommend early exploration and fixation of these injuries.

Review of Statutory Obligations for Reporting Ballistic Injuries

Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states' reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries.

Methods

Google and PubMed searches were performed utilizing keywords "ballistic," "gunshot," "physician," and "reporting" as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region.

Results

All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region.

Conclusions

Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.

Fatal and non-fatal firearm-related injuries in Canada, 2016-2020: a population-based study using three administrative databases

BACKGROUND

Firearms are a substantial cause of injury-related morbidity and mortality in Canada and globally, though evidence from contexts other than the USA is relatively limited. We examined deaths, hospitalizations and emergency department (ED) visits due to firearm-related injuries in Canada to identify population groups at increased risk of fatal and non-fatal outcomes.

METHODS

We conducted a population-based study using three national administrative databases on deaths, hospitalizations, and ED visits. ICD-10 codes were used to identify firearm-related injuries from January 1, 2016, through December 31, 2020. Fatal and non-fatal firearm injuries were classified as suicide/self-harm, homicide/assault, unintentional, undetermined or legal intervention injuries. We analyzed the data with counts, rates and proportions, stratified by sex, age group, province/territory, and year.

RESULTS

Over the 5-year period, we identified 4005 deaths, 3169 hospitalizations, and 2847 ED visits related to firearm injuries in various jurisdictions in Canada. Males comprised the majority of fatal and non-fatal injury cases. The highest rates of fatal and non-fatal firearm injuries were among 20- to 34-year-olds. The leading cause of fatal firearm injuries was self-harm (72.3%). For non-fatal firearm hospitalizations and ED visits, assault (48.8%) and unintentional injuries (62.8%) were the leading causes of injury. Rates varied by province and territory.

CONCLUSIONS

Our results showed that males comprised the majority of fatal and non-fatal firearm injuries in Canada. The rates of both fatal and non-fatal firearm injuries were highest among the 20- to 34-year-old age group. This comprehensive overview of the epidemiology of firearm injuries in Canada provides baseline data for ongoing surveillance and policy evaluation related to public health interventions.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

National trends in pediatric firearm and automobile fatalities

BACKGROUND

Successful public health policies and injury prevention efforts have reduced pediatric automobile fatalities across the United States. In 2019, firearm injuries exceeded motor vehicle crashes (MVC) as the leading cause of childhood death in Colorado. We sought to determine if similar trends exist nationally and if state gun laws impact firearm injury fatality rates.

METHODS

Annual pediatric (≤19 years-old) fatality rates for firearm injuries and MVCs were obtained from the CDC WONDER database (1999-2020). State gun law scores were based on the 2014-2020 Gifford's Annual Gun Law Scorecard and strength was categorized by letter grades A-F. Poisson generalized linear mixed models were used to model fatality rates. Rates were estimated for multiple timepoints and compared between grade levels.

RESULTS

In 1999, the national pediatric fatality rate for MVCs was 248% higher than firearm injuries (Incidence Rate Ratio (IRR) 95% Confidence Interval (CI): 2.25-2.73, p<0.0001). By 2020, the fatality rate for MVCs was 16% lower than that of firearm injuries (IRR 95% CI: 0.75- 0.93, p = 0.0014). For each increase in letter grade for gun law strength there was an 18% reduction in the firearm fatality rate (IRR 95%CI: 0.78-0.86, p<0.0001). States with the strongest gun laws (A) had a 55% lower firearm fatality rate compared to those with the weakest laws (F).

CONCLUSION

Firearm injuries are the leading cause of death in pediatric patients across the United States. State gun law strength has a significant impact on pediatric firearm injury fatality rates. New public health policies, political action, media attention and safer guns are urgently needed to curb this national crisis.

LEVEL OF EVIDENCE/STUDY TYPE

Level III, retrospective.

US racial and sex-based disparities in firearm-related death trends from 1981-2020

BACKGROUND

Firearms cause the most suicides (60%) and homicides (36%) in the US. The high lethality and availability of firearms make them a particularly dangerous method of attempted violence. The aim of this study was to study US trends in firearm suicide and homicide mortality and years of potential life lost before age 75 (YPLL-75) between 1981 and 2020.

METHODS

Data in this cross-sectional study were collected between 1981 and 2020 from the Centers for Disease Control and Prevention (CDC)'s WISQARS database for fatal injury and violence. Data from the US population were considered for all age groups and were divided by racial groups and sex for analysis.

RESULTS

Those most heavily impacted by firearm homicide were Black, with homicide age-adjusted death rates almost seven times higher than White people. A spike in firearm homicide deaths occurred between 2019 and 2020, with Black people having the largest increase (39%). White people had the highest rates of firearm suicide, and suicide death rates increased between 2019 and 2020. Increases in homicide and suicide YPLL-75 between 2011 and 2020 had most heavily impacted minority populations. Men had a firearm suicide rate that was seven times higher than women, and a firearm homicide rate that was five times higher than women.

CONCLUSION

This study demonstrated that Black and White men were most impacted by firearm deaths, and that firearm homicide and suicide rates increased between 2019 and 2020 for all racial groups except Asian/Pacific Islander. Our results suggest that prevention efforts should focus on specific demographic factors and articulate the urgency to mitigate firearm-related deaths in the US.

Income support policies and firearm violence prevention: A scoping review

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact.