Mechanism of penetrating injury mediates the risk of long-term adverse outcomes for survivors of violent trauma

Survivor's remorse

ABSTRACT

In urban, large metropolitan trauma centers, we are accustomed to seeing the most gruesome morbidity and mortality in medicine. By far, the most devastating morbidity and mortality to observe are those inflicted on one human being to another. Gun violence is pervasive in this industrialized country, and it impacts us all. Staff, residents, and faculty in trauma centers bear the brunt of this trauma, second only to the families and communities that suffer the loss of loved ones. This burden is especially heavy for health care workers who share the same ethnic background of those who are disproportionately affected by interpersonal gun violence. Survivors of gun violence exist on a spectrum of chronic illness that ranges in physical and mental morbidity and social disruption in loss of wages and capabilities. This disease not only infects those wounded or killed but also transmits through communities and generations. Urban violence exists because of historic and systematic racism. It continues to persist because racism creates inequities in the quality of education, housing, and investment in urban environments, exacerbated by residential segregation. For two providers, a trainee and a faculty member of African descent, conscious of the determinants that create gun violence, it is overwhelming. We, as health care providers, must tell our stories and the stories of those whose voices are not empowered. We can hope that, by sharing these experiences, we stimulate action and change by raising the moral consciousness of those unaware of the tragedies we witness every day.

Firearm injury among people experiencing homelessness: Cross-sectional evidence from a national survey of United States emergency departments

Objectives

Persons experiencing homelessness (PEH) are at high risk for violent victimization. This study leverages unique data from a national study in the United States of America to provide estimates of non-fatal firearm injury among PEH and to describe the contexts related to injury, such as substance use, intent of the injury, and precipitating interpersonal factors.

Study design

Cross-sectional.

Methods

Data from the 1993-2020 National Electronic Injury Surveillance System-Firearm Injury Surveillance Study (NEISS-FISS) were used to describe the context and characteristics of non-fatal firearm injury among PEH aged 16 years or older. Homeless status and substance use data were extracted from a de-identified narrative field. Estimates were weighted to account for the NEISS-FISS complex sampling design.

Results

Probable homelessness was identified in 0.10% of cases (n = 3,225). Substance use was documented in 22.73% of cases. Assault comprised 82.64% of injuries. Patients were mostly male (81.38%). Missing data were common on contextual variables: verbal argument (64.62%), physical fight (54.48%) or other criminal activity (62.33%).

Conclusions

Assault is a leading cause of non-fatal firearm injury for PEH and is greater than rates of assault in non-fatal firearm injuries in the general population. Substance use was documented in nearly one quarter of patients, although this is less than expected given prior evidence. Reliance on narrative fields for key variables likely underestimates rates of PEH and substance use.

National trends and resource associated with recurrent penetrating injury

BACKGROUND

While recurrent penetrating trauma has been associated with long-term mortality and disability, national data on factors associated with reinjury remain limited. We examined temporal trends, patient characteristics, and resource utilization associated with repeat firearm-related or stab injuries across the US.

METHODS

This was a retrospective study using 2010-2019 Nationwide Readmissions Database (NRD). NRD was queried to identify all hospitalizations for penetrating trauma. Recurrent penetrating injury (RPI) was defined as those returned for a subsequent penetrating injury within 60 days. We quantified injury severity using the International Classification of Diseases Trauma Mortality Prediction model. Trends in RPI, length of stay (LOS), hospitalization costs, and rate of non-home discharge were then analyzed. Multivariable regression models were developed to assess the association of RPI with outcomes of interest.

RESULTS

Of an estimated 968,717 patients (28.4% Gunshot, 71.6% Stab), 2.1% experienced RPI within 60 days of the initial injury. From 2010 to 2019, recurrent gunshot wounds increased in annual incidence while that of stab cohort remained stable. Patients experiencing recurrent gunshot wounds were more often male (88.9 vs 87.0%, P<0.001), younger (30 [23-40] vs 32 [24-44] years, P<0.001), and less commonly insured by Medicare (6.5 vs 11.2%, P<0.001) compared to others. Those with recurrent stab wounds were younger (36 [27-49] vs 44 [30-57] years, P<0.001), less commonly insured by Medicare (21.3 vs 29.3%, P<0.001), and had lower Elixhauser Index Comorbidities score (2 [1-3] vs 3 [1-4], P<0.001) compared to others. After risk adjustment, RPI of both gunshot and stab was associated with significantly higher hospitalization costs, a shorter time before readmission, and increased odds of non-home discharge.

CONCLUSION

The trend in RPI has been on the rise for the past decade. National efforts to improve post-discharge prevention and social support services for patients with penetrating trauma are warranted and may reduce the burden of RPI.

Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019 : A Cohort Study

BACKGROUND

Firearm injuries are a public health crisis in the United States.

OBJECTIVE

To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury.

DESIGN

Multicenter, observational, cohort study.

SETTING

Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019.

PARTICIPANTS

Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury.

MEASUREMENTS

Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury.

RESULTS

We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years.

LIMITATIONS

Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals.

CONCLUSION

Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence.

PRIMARY FUNDING SOURCE

Emergency Medicine Foundation-AFFIRM and Missouri Foundation for Health.

Exposure to Neighborhood Racialized Economic Segregation and Reinjury and Violence Perpetration Among Survivors of Violent Injuries

Importance

Much is unknown about how individual and neighborhood factors converge in the association with risk for violent reinjury and violence perpetration.

Objectives

To investigate the association of exposure to neighborhood racialized economic segregation with reinjury and use of violence against others among survivors of violent penetrating injury.

Design, Setting, and Participants

This retrospective cohort study was performed using data obtained from hospital, police, and state vital records. The study was performed at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. The cohort included all patients treated for a nonfatal violent penetrating injury from 2013 to 2018. Patients with no Boston metropolitan area home address were excluded. Individuals were followed up through 2021. Data were analyzed from February to August 2022.

Exposure

American Community Survey data were used to measure neighborhood deprivation using the racialized economic Index of Concentration at the Extremes (ICE) for patient residential address upon hospital discharge. ICE was measured on a scale from -1 (most deprived) to 1 (most privileged).

Main Outcomes and Measures

Primary outcomes were violent reinjury and police-reported perpetration of violence within 3 years of an index injury.

Results

Of 1843 survivors of violence (median [IQR] age, 27 [22-37] years; 1557 men [84.5%]; 351 Hispanic [19.5%], 1271 non-Hispanic Black [70.5%], and 149 non-Hispanic White [8.3%] among 1804 patients with race and ethnicity data), the cohort was skewed toward residing in neighborhoods with higher racialized economic segregation (median [IQR] ICE = -0.15 [-0.22 to 0.07]) compared with the state overall (ICE = 0.27). There were police encounters for violence perpetration among 161 individuals (8.7%) and violent reinjuries among 214 individuals (11.6%) within 3 years after surviving a violent penetrating injury. For each 0.1-unit increase in neighborhood deprivation, there was a 13% (hazard ratio [HR], 1.13; 95% CI, 1.03 to 1.25; P = .01) increase in risk of violence perpetration but no difference in risk for violent reinjury (HR, 1.03; 95% CI, 0.96 to 1.11; P = .38). The greatest occurrence for each outcome was within the first year after index injury; for example, incidents of violence perpetration occurred among 48 of 614 patients (7.8%) at year 1 vs 10 of 542 patients (1.8%) at year 3 in tertile 3 of neighborhood deprivation.

Conclusions and Relevance

This study found that living in a more economically deprived and socially marginalized area was associated with increased risk of using violence against others. The finding suggests that interventions may need to include investments in neighborhoods with the highest levels of violence to help reduce downstream transmission of violence.

A systematic review of recurrent firearm injury rates in the United States

OBJECTIVES

To conduct a systematic review of methodologies, data sources, and best practices for identifying, calculating, and reporting recurrent firearm injury rates in the United States.

METHODS

In accordance with PRISMA guidelines, we searched seven electronic databases on December 16, 2021, for peer-reviewed articles that calculated recurrent firearm injury in generalizable populations. Two reviewers independently assessed the risk of bias, screened the studies, extracted data, and a third resolved conflicts.

FINDINGS

Of the 918 unique articles identified, 14 met our inclusion criteria and reported recurrent firearm injury rates from 1% to 9.5%. We observed heterogeneity in study methodologies, including data sources utilized, identification of subsequent injury, follow-up times, and the types of firearm injuries studied. Data sources ranged from single-site hospital medical records to comprehensive statewide records comprising medical, law enforcement, and social security death index data. Some studies applied machine learning to electronic health records to differentiate subsequent new firearm injuries from the index injury, while others classified all repeat firearm-related hospital admissions after variably defined cut-off times as a new injury. Some studies required a minimum follow-up observation period after the index injury while others did not. Four studies conducted survival analyses, albeit using different methodologies.

CONCLUSIONS

Variability in both the data sources and methods used to evaluate and report recurrent firearm injury limits individual study generalizability of individual and societal factors that influence recurrent firearm injury. Our systematic review highlights the need for development, dissemination, and implementation of standard practices for calculating and reporting recurrent firearm injury.

Racial and Ethnic Disparities in Violent Penetrating Injuries and Long-Term Adverse Outcomes

Violent injury is known to be a chronic, recurrent issue, with high rates of recidivism following initial injury. While the burden of violence is disproportionately felt among young Black men and in communities of color, examination of distinct risk factors and long-term outcomes for other racial and ethnic groups could lead to improved violence intervention strategies. In this study, we examined the risk of violent penetrating injury and long-term adverse outcomes by race and ethnicity. This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury between 2006 and 2016. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI) for the risk of all-cause mortality and violent re-injury at one and 3 years after surviving a penetrating injury.Of the 4191 victims of violent injury, 12% were White, 18% were Hispanic, and the remaining 70% self-identified as Black. Within 3 years after initial injury, Black patients were at the greatest risk of all-cause violent re-injury (vs. Hispanic: HR = 1.46, 95%CI[1.15,1.85], p = 0.002; vs. White: HR = 1.89, 95%CI[1.40,2.57], p < 0.0001), particularly by gunshot wound (vs. Hispanic: HR = 2.04, 95%CI[1.29,3.22] p = 0.002; vs. White: HR = 2.34, 95%CI[1.19,4.60], p = 0.01). At 3-years following initial injury, White patients were at 2.03 times the risk for all-cause mortality, likely due to a 4.96 times greater risk of death by drug or alcohol overdose for White patients compared to Black patients (HR = 4.96, 95%CI[2.25,10.96], p < 0.0001). In conclusion, Black survivors of violent injury have a significantly higher risk of violent re-injury, particularly by gun violence, while White patients are at the highest risk for mortality due to the incidence of drug and alcohol overdose. Violence intervention programs with similar patient populations should explore options to collaborate with drug treatment programs to reach this vulnerable population.

Rare penetrating abdominal injury caused by falling from height: Miraculously good prognosis

Fall from height causing penetrating abdominal visceral injuries is rare condition leading to abdominal multiorgan damage. It carries high mortality. A case of construction site worker sustaining penetrating visceral injuries by falling from height leading to impalement of steal bar from anus presented to our hospital and managed by timely evacuation from site of accident to hospital, resuscitations, radiological investigations and multi-Disciplinary team management lead to successful outcome. Our protocol for such cases will be discussed with references.

Violence against women in Israel: injury mechanisms and clinical outcomes following hospitalization

PURPOSE

The objective of this study was to evaluate the relative contributions of different mechanisms of assault to injury and mortality in women in Israel.

METHODS

We identified females hospitalized between 2011 and 2020 following an assault, secondary to blunt, stabbing, or shooting mechanisms of injury, in the Israeli Program for Registration of Trauma Patients (National Trauma Registry). To avoid bias due to temporary hospitalizations for non-medical reasons, we included patients with injuries graded as Abbreviated Injury Scale ≥ 2.

RESULTS

Females accounted for 8.1% (926/11,486) of assault patients in the study population. Compared to males, females were older (40.7 vs. 31.0 years; p < 0.001), more commonly injured by the blunt trauma mechanism (72.1 vs. 48.6%; p < 0.001), and more commonly injured at a place of residence (50.9 vs. 8.2%; p < 0.001). There were no differences in the number of body areas injured, severe Injury Severity Score, and median hospitalization. Males were operated more commonly (44.6 vs. 40.0%; p = 0.008). Mortality in females and males was similar (2.8 vs. 2.3%; p = 0.43). Secondary analysis revealed that blunt injuries were responsible for 61.2% of the severe cases (ISS ≥ 16), 61.4% of the operations, 54.9% of the Intensive Care Unit (ICU) admissions, and 53.8% of the mortality observed in females. When compared to males injured by blunt trauma, females injured by this mechanism were older (43.0 ± 24.7 vs. 32.8 ± 16.1 years; p < 0.001) and had higher mortality (2.1 vs. 0.9%; p = 0.007).

CONCLUSIONS

Assault by mechanisms other than stabbing and shooting should be recognized as a source of severe morbidity and mortality in females.

Trends in Violent Penetrating Injuries During the First Year of the COVID-19 Pandemic

IMPORTANCE

Public health measures instituted to reduce the spread of COVID-19 led to severe disruptions to the structure of daily life, and the resultant social and financial impact may have contributed to an increase in violence.

OBJECTIVE

To examine the trends in violent penetrating injuries during the first COVID-19 pandemic year compared with previous years.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study was performed to compare the prevalence of violent penetrating injuries during the first COVID-19 pandemic year, March 2020 to February 2021, with the previous 5 years, March 2015 to February 2020. This study was performed among all patients with a violent penetrating injury presenting at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. Data were analyzed from January 4 to November 29, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the incidence and timing of emergency department presentation for violent penetrating injuries during the first year of the COVID-19 pandemic compared with the previous 5 years. Patient demographics and injury characteristics were also assessed.

RESULTS

A total of 2383 patients (median [IQR] age, 29.5 [23.4-39.3] years; 2032 [85.4%] men and 351 [14.6%] women) presenting for a violent penetrating injury were evaluated, including 1567 Black patients (65.7%), 448 Hispanic patients (18.8%), and 210 White patients (8.8%). There was an increase in injuries during the first pandemic year compared with the previous 5 years, with an increase in shootings (mean [SD], 0.61 [0.89] injuries per day vs 0.46 [0.76] injuries per day; P = .002) but not stabbings (mean [SD], 0.60 [0.79] injuries per day vs 0.60 [0.82] injuries per day; P = .78). This surge in firearm violence began while Massachusetts was still under a stay-at-home advisory and before large-scale racial justice protests began. Patients presenting with violent penetrating injuries in the pandemic surge months (April-October 2020) compared with the same period in previous years were disproportionately male (153 patients [93.3%] vs 510 patients [87.6%]; P = .04), unemployed (70 patients [57.4%] vs 221 patients [46.6%]; P = .03), and Hispanic (40 patients [26.0%] vs 99 patients [17.9%]; P = .009), with a concurrent decrease in White patients (0 patients vs 26 patients [4.7%]), and were more likely to have no previous history of violent penetrating injury (146 patients [89.0%] vs 471 patients [80.9%]; P = .02).

CONCLUSIONS AND RELEVANCE

These findings suggest that unprecedented measures implemented to mitigate the spread of COVID-19 were associated with an increase in gun violence. As the pandemic abates, efforts at community violence prevention and intervention must be redoubled to defend communities against the epidemic of violence.