Homicide, suicide, motor vehicle crash, and fall mortality: United States' experience in comparative perspective

Lifetime Risk of Death From Firearm Injuries, Drug Overdoses, and Motor Vehicle Accidents in the United States

BACKGROUND

News media and policy makers frequently discuss deaths from firearms, drug overdoses, and motor vehicle accidents. However, this information is generally presented as absolute numbers or annual rates. Cumulative lifetime risk may be an additional useful metric for understanding the impact of these causes of death.

METHODS

Data on all-cause firearm, drug overdose, and motor vehicle accident deaths were obtained from the US Centers for Disease Control and Prevention (CDC) for the year 2018. Age-specific death rates were used to estimate the cumulative risk of firearm, drug overdose, and motor vehicle accident deaths from birth to age 85 after accounting for other causes of death.

RESULTS

The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents was 0.93% (95% confidence interval [CI], 0.92%-0.94%), 1.52% (95% CI, 1.51%-1.53%), and 0.92% (95% CI, 0.91%-0.93%), respectively. Black males had a 2.61% (95% CI, 2.55%-2.66%) lifetime risk of firearm death, indicating that 1 out of 38 black males will die from firearms if current death rates persist. Residents of West Virginia had a 3.54% lifetime risk of drug overdose death, equivalent to 1 out of every 28 residents dying from overdoses.

CONCLUSIONS

The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents is substantial and varies greatly across demographic subgroups and states.

Orthopaedic injuries associated with fall from floor forty-seven

This case report provides background reviewing mortality rates associated with falls from height before detailing the clinical history of a patient who survived a fall from a height of 43 stories. A multidisciplinary team treated both orthopaedic and nonorthopaedic injuries with the ultimate goal of preserving potential for independent function. A discussion of relevant pathoanatomy seen after falls from a height is included, and the discussion concludes with a review of damage control orthopaedics.

Cost Analysis of Vertical Deceleration Injury in the Acute Setting

INTRODUCTION

Vertical deceleration injury is a known but not well understood form of blunt injury in both the urban and rural environment. The purpose of this study was to investigate the financial cost of treatment for this specific mechanism of injury in the acute care setting, and to continue to expand a fall prevention program from our unit.

METHOD

This is a prospective review of vertical deceleration injuries admitted over a 2-year period to a Level I trauma center. Patients were followed until discharge to either home or rehabilitation facilities.

RESULTS

Ninety-nine patients who sustained a vertical deceleration injury from a height of ≥ 6 ft were identified from our Trauma Registry database. The length of hospital stay, including rehabilitation, ranged from 1 to 78 days (mean, 13.1 days). The mean injury severity score (ISS) was 16.4 (range, 4-75). The average height of fall was 19.5 ft (range, 6-110 ft) with a mean impact velocity of 23 mph (range, 13-58). The cost of hospitalization was significantly correlated to the ISS score (correlation = 0.558, p < 0.001); and as expected, higher ISS scores yielded higher costs (χ(2) = 34.7, p < 0.001). We found that the best predictor variable for the cost of treatment for vertical deceleration injury is the ISS score with a regression equation of: Cost = $19,578 + ($6,609 × ISS). The average cost per fall incident was $91,435 (range $5,006-$948,957) for vertical deceleration injuries.

CONCLUSION

The cost of treatment of vertical deceleration injuries is very high. Hospital stays are prolonged and rehabilitation needs frequent. Overall, ISS is the best predictor of cost of treatment and length of hospital stay.

Contribution of an affect-associated gene to human longevity: prevalence of the long-allele genotype of the serotonin transporter-linked gene in Japanese centenarians

Negative affect such as depression and anxiety has been reported to be associated with morbidity and mortality, and polymorphisms of the serotonin transporter (5HTT) gene may be associated with such affect disorders. Hypothesizing that 5HTT gene polymorphisms could influence human longevity via negative affect; we compared the polymorphic variation of the 5HTT gene between 265 Japanese centenarians and control subjects. In addition, we evaluated the relationships between the 5HTT genotype and the physical, cognitive, and biologic status of centenarians, as indicated by the Barthel Index, the Mini-Mental State Examination, and serum albumin concentration, respectively. The frequency of the l/l genotype and the l allele was significantly greater in centenarians than in younger control subjects, particularly women. A significant effect of the 5HTT genotype on serum albumin concentration was observed in both sexes. Although, there was sex optionality, the l allele may carry a longevity advantage possibly through behavioral mechanisms.

Population characteristics of traffic accident-related deaths in Japan and Ireland, 1950-2000

To compare epidemiological characteristics of traffic accidents in Japan and Ireland, we analyzed mortality and the negative effect on life expectancy between 1950 and 2000 and generated a multivariate model. The characteristics were similar in the two countries: The time trends showed an increase in mortality followed by a decrease. The mortality rates were about 13 and 5/100,000 for males and females, respectively, in 2000. Correlation coefficients for sex were over 0.9. Age distribution obeyed the natural logarithm regularity. The negative effect on life expectancy was about 0.34 year for males, and 0.13 year for females. The economic level was positively associated with mortality, whereas "number of vehicles owned" was associated negatively. In conclusion, we can take advantage of the broad consistencies in these two countries when we draw up an intervention strategy. Any preventive strategy should be directed to the young, particularly males.

Sex and age distribution in transport-related injuries in Tehran

Intercountry or regional differences in patterns of injury by the road user type have significant implication for prevention policies. In order to have an estimate from the existing conditions of transport-related injuries (TRIs) and especially to evaluate sex and age distribution of traffic accident victims, we analyzed information of 8426 hospitalized trauma patients during 13 months of data gathering process. Forty-five percent of the injuries were related to car accidents and men/women ratio in these patients was 4.2/1. The highest men/women ratio was (16/1) for motorcyclists, while the lowest ratio (1/1), was for rear seat car passengers. Mean (+/-S.D.) age of the patients was 31 (+/-18), and men were nearly 2 years younger than women (33 versus 31). Sixty-seven percent of the females' and 44% of the males' injuries were related to pedestrian crashes. Motorcycle-related injuries in men and car passenger related injuries in women were the second most common type of crash (42 and 22%, respectively). The use of protective devices in our population was worrisome. In only 6% of the male motorcyclists helmet use was reported, and 3% of the male car occupants had used seatbelts at the time of the accident. The condition in the female population was much worse and no use of the protective devices was reported in this group of the patients. Crude mortality rate in men was nearly two times that of women (6.2% versus 3.8%). After adjustment for age, injury severity score (ISS) and category of the road users, men and women had similar mortality rate.

Cross-national comparison of injury mortality: Los Angeles County, California and Mexico City, Mexico

BACKGROUND

Cross-national comparisons of injury mortality can suggest possible causal explanations for injuries across different countries and cultures. This study identifies differences in injury mortality between Los Angeles (LA) County, California and Mexico City DF, Mexico.

METHODS

Using LA County and Mexico City death certificate data for 1994 and 1995, injury deaths were classified according to the International Classification of Diseases Ninth Revision-Clinical Modification external cause of injury codes. Crude, gender-, and age-adjusted annual fatality rates were calculated and comparisons were made between the two regions.

RESULTS

Overall and age-adjusted injury death rates were higher for Mexico City than for LA County. Injury death rates were found to be higher for young adults in LA County and for elderly residents of Mexico City. Death rates for motor vehicle crashes, falls, and undetermined causes were higher in Mexico City, and relatively high rates of poisoning, homicide, and suicide were found for LA County. Motor vehicle crash and fall death rates in Mexico City increased beginning at about age 55, while homicide death rates were dramatically higher among young adults in LA County. The largest proportion of motor vehicle crash deaths was to motor vehicle occupants in LA County and to pedestrians in Mexico City.

CONCLUSIONS

These findings illustrate the importance of primary injury prevention in countries having underdeveloped trauma care systems and should aid in setting priorities for future work. The high frequency of pedestrian fatalities in Mexico City may be related to migration of rural populations, differing vehicle characteristics and traffic patterns, and lack of safety knowledge. Mexico City's higher rate of fall-related deaths may be due to concurrent morbidity from chronic conditions, high-risk environments, and delay in seeking medical treatment.

Does gender make a difference in the risk of falls? A Japanese study

The number of elderly people in the world is increasing at a remarkable rate and the rate of aging in Japan is the world's highest. According to a statistical survey done in 1994, people over 65 years of age constitute 14.1% of the Japanese population. In addition, the Japanese average life expectancy in 1991 was the highest in the world, reaching 76.1 years for men and 82.1 years for women. A prominent health problem among elderly people is immobility which can result in elderly patients becoming bedridden (Eto, 1992). Recently, the problem of falls among the frail elderly has received increased interest. Although fall mortality in the Japanese elderly was not as high as those of France or the United States (Rockett & Smith, 1989), falls lead to deterioration in the health and physical status of the elderly. If falls could be reduced among the elderly, many of the health problems attributed to immobility among the Japanese elderly would be reduced. Some falls have a single and obvious cause, but most appear to result from several factors. With better knowledge of the causes and risk factors for falls among the elderly, effective preventive measures can be instituted (Tinetti, Speechley, & Ginter, 1988; Ryynanen, 1994; Teno, Kiel, & Mor 1990). There are few studies concerning falls among the institutionalized elderly (Haga, Shibata, Shichida, Matsuzaki, & Hatano, 1986) and community-dwelling elderly in Japan (Yasumura et al., 1994; Niino et al., 1995; Suzuki et al., 1991, 1992; Suzuki, Yamada, Takahashi, & Tsuchiya, 1991; Suzuki, Yamada, & Tsuchiya, 1993). The purpose of this study was to investigate falls among the elderly, selected at random, who live in Koga, a city in eastern Japan.

The epidemiology of homicide in Chicago

Public health agencies across the country are beginning to view violence as a problem that demands a public health response. However, before such a response can be mounted effectively, there must be a sound data-based understanding of this epidemic. With this in mind, the Chicago Department of Public Health implemented an epidemiological analysis of homicide in the city. Using vital records, police data, and census data, we found that the city's homicide rate in 1993 was 31 per 100,000 population. This rate placed Chicago 14th among other large cities in the United States and 4th out of the eight cities with a population > 1 million. The homicide rate in the city has been increasing over the past 30 years, but not steadily. For some intervals, the homicide rate has remained almost constant. African Americans, Hispanics, the young, and males are overrepresented in the epidemic. While guns accounted for almost 75% of all homicides in Chicago in 1993, gangs accounted for only 15%. Homicide cannot be viewed in isolation from the context of society. The literature suggests that poverty and racism are important risk factors for this epidemic. Although we cannot wait until these risk factors are remedied to develop violence prevention interventions, we also cannot proceed effectively without understanding this context.

Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional high falls

We analysed the pattern of injury of 101 adult patients who were treated in our Trauma Center after a fall from an average height of 7.2 m between 1987 and 1990. In 62 patients the fall was accidental, and 39 jumped with suicidal intent. The most common injuries were fractures of the thoracic and lumbar spine (83.0 per cent) especially of the thoracolumbar junction. The pattern of limb injuries is towards a significant preference of the metaphyseal and epiphyseal parts of the bones of the distal joints (wrist, elbow, ankle, subtalar). Fractures of the diaphyseal areas and the proximal joints (shoulder, humerus, hip, femur) were rare. The incidence of thoracic (20.8 per cent) and pelvic injuries (30.0 per cent) was relatively lower. Blunt abdominal injury (5.9 per cent) was rare after a fall from a great height. Head injuries occurred in only 27 per cent of our patients who all survived their transport to hospital. There is no significant difference in injury patterns between deliberate and accidental falls, but there is a higher number of isolated injuries in all patients after unsuccessful suicidal jumps.

Age-period-cohort analysis of motor vehicle mortality in Taiwan, 1974-1992

The aim of this study was to examine the effects of age, calendar period of death and birth cohort in motor vehicle mortality in Taiwan over the period 1974-1992. A log-linear model modified from the method of Osmond and Gardner (Stat. Med. 1: 245-259; 1982) was used. Age turned out to be a significant predictor of motor vehicle mortality. The most risky group (over 70 years) had 27.1 and 16.3 times the mortality of the least risky group (5-9 years, 10-14 years) for males and females respectively. The period effect showed a continuously increasing mortality trend since 1974 in females. The pattern in males is similar except that it has slightly leveled off in recent years. The birth cohorts at the highest risk of motor vehicle death were those born between 1979 and 1983 for both sexes. However, males born between 1929 and 1933 also had a high mortality. This analysis provided a better understanding of the trend of mortality from motor vehicle crashes.

Effect of valvular heart diseases, migraine headaches, and perianal diseases on the risk of involvement in motor vehicle crashes

Impaired health can interfere with driving performance. We have launched this investigation to identify in professional military drivers health parameters that might be associated with involvement in motor vehicle crashes (MVCs). All Israel Defense Forces professional male drivers (N = 5,605) conscripted into compulsory military service between April 1, 1988 and April 1, 1990 were divided into two groups according to whether (N = 1,300) or not (N = 4,305) the driver was involved in MVCs during the same time frame. Using the multivariate Cox model, a significant association was shown between involvement in MVCs and the following health parameters: mild-to-moderate valvular heart disease (p = 0.0002, chi 2 = 13.89), migraine headaches (p = 0.009, chi 2 = 6.91), and perianal diseases (p = 0.006, chi 2 = 7.44). We hypothesize that interference with the driver's performance level may be a result of the discomfort associated with those clinical conditions. It is possible that interference with the personal performance level decreased the ability of the driver to cope with the specific driving task demands and resulted in the involvement of the driver in MVCs. We suggest that because of the high social and economic costs associated with road accidents, it is important to investigate further the association of involvement in MVCs and health problems. If our findings are confirmed in the future studies, intervention programs to reduce MVC rates would be suggested and conducted among professional drivers.

Injury from assault in New Zealand: an increasing public health problem

Injury purposely inflicted by other persons is a significant public health problem accounting for approximately 4 per cent of all injury hospitalisations in New Zealand. National injury morbidity data for the years 1979-1988 were examined. These data were used to identify the characteristics of victims of assault who were hospitalised, the nature of the injuries they sustained, and the circumstances in which the injuries were inflicted. The incidence of hospitalisations in 1988 was 73.7 per 100,000 persons per year. A significant increase in the rate of hospitalisations over the decade 1979-1988 was identified. The rates for males were higher than those for females, with males 20-24 years of age most at risk. Maori had higher rates than non-Maori. Fights or brawls were the leading cause of hospitalisation. The most common place of occurrence was private homes, followed by streets and highways, and licensed premises. The findings with regard to age, sex, employment status and use of weapons were consistent with earlier studies. A higher proportion of incidents occurring in the home was attributed to differences in selection of cases between studies. An indication of underreporting by women was attributed to concealment of intentionality, possible owing to fear of reprisal. Standard hospital reporting procedures were proposed as a means of improving identification.

Homicide in New Zealand: an increasing public health problem

Injury purposely inflicted by other persons is a significant public health problem as well as a criminal problem. It accounts for approximately 3 per cent of all deaths from injury in New Zealand. National injury mortality data for the period 1978 to 1987, supplemented by reference to files of the Coroner's Court and the High Court, were used to identify the characteristics of victims of homicide, the nature of the injuries they sustained, and the circumstances in which the injuries were inflicted. The mortality rate from homicide for the 10-year period was 1.6 per 100,000 persons per year. A significant increase in the rate of homicide was identified. The rates for males were higher (2.0) than those for females (1.2), with those 20 to 24 years of age most at risk. Maori had higher rates than non-Maori. Homicides were most frequently committed with cutting and piercing instruments, and most commonly occurred in private homes. Homicides were most likely to occur on Fridays or Saturdays, between the hours of 6 p.m. and 6 a.m. In 55 per cent of homicides the victim and assailant were known to one another. Unemployment, membership of ethnic minority groups, availability of weapons, the private nature of interactions in the home, alcohol consumption, and stress in personal relationships were all identified as factors associated with homicide in the decade under study. The implications of these findings for the prevention of injury from assault are discussed.

Intentional and unintentional injuries in women. An overview

Injuries are the leading cause of death for females 1 to 34 years old, and a major source of preventable morbidity and mortality in middle-aged and elderly women. In the United States, 43,000 women die from injuries and approximately 1 million women are hospitalized for injuries annually. The leading causes of injury death in women are motor vehicle-related injuries (34%), suicide (14%), falls (14%), and homicide (12%). Injuries of particular concern include fatal and nonfatal falls in elderly women, homicides among young black women, suicides among young white women, work-related homicides among female convenience store workers, and fatal and nonfatal injuries in pregnant and nonpregnant women associated with domestic violence. Strategies to prevent most types of injuries are either known or being investigated. Increased efforts to develop, implement, and evaluate such interventions would help to reduce the toll of injuries on women's health.

Mortes no trânsito do Rio de Janeiro, Brasil

A evolução urbana do município do Rio de Janeiro durante o século XX, especialmente a partir da sua segunda metade, é fortemente marcada por crescentes privilégios concedidos ao crescimento da utilização dos meios de transporte de massa e, principalmente, individuais, feitos por veículos a motor de explosão. Uma das conseqüências desta política é a ascenção da mortalidade por acidentes de trânsito, verificada durante a década de 80, entre homens e mulheres de todas as idades. Neste trabalho demonstra-se também que, em 1990, apenas cerca de 1/3 das vítimas fatais nos acidentes de trânsito estavam "embarcadas" nos veículos. Portanto, a maioria dos óbitos por este tipo de acidente, cerca de 2/3, ocorreu por atropelamentos. Isto indica a necessidade de o poder público reverter a prioridade na prevenção das mortes por acidentes de trânsito em favor de medidas eficazes que protejam os pedestres.

Covert suicide among elderly Japanese females: questioning unintentional drownings

A hypothesis is generated that despite high reported rates, suicide among elderly Japanese females is substantially underestimated due to misclassification of drowning suicides (ICD-9 E954) as unintentional drownings (ICD-9 E910). Data are adapted from 1979-1981 age-, sex- and cause-specific mortality tabulations for Japan, the United States, Australia, France, New Zealand, Norway, Sweden and the United Kingdom. Between ages 55 and 74 years, unintentional drowning rates for males and females in Japan begin to diverge sharply from those of comparison countries. By ages 75 and older, the rate for Japanese females is 13.5 per 100,000, which exceeds comparison rates by 7- to 15-fold. Although drowning suicide rates in this population are also high, its ratio of drowning suicides to unintentional drownings declines precipitously beyond ages 35-44. Excess drowning suicide underestimation among Japanese females is suggested by the absence of a similar change among the males and evidence of both a lack of drowning witnesses and sex differentials in life expectancy, living arrangements and suicide methods. A preliminary test of the drowning suicide hypothesis is proposed which incorporates psychological autopsies.

The pedestrian trauma patient. Perspectives from a psychiatric consultation service

The hospital course of adult pedestrians injured by automobiles and treated by a university trauma service over a 12-month period was reviewed to evaluate the prevalence, recognition, and intervention of substance use and suicidal behavior. The study showed that the pedestrian trauma patient had a dramatically high rate of substance use and a surprisingly low index of suspicion of suicide attempt by the treatment team as a cause of the accident. Appropriate intervention might greatly reduce the financial and human cost of trauma care, but awareness and identification of these risk factors must be taught first.

Violência velada e revelada: estudo epidemiológico da mortalidade por causas externas em Duque de Caxias, Rio de Janeiro

Este trabalho é parte de um estudo em que se aborda, interdisciplinarmente, o processo de violência/saúde no município de Duque de Caxias, processo este entendido como uma cadeia onde se expressam as violências estrutural, da resistência e da delinqüência, cujos reflexos se fazem presentes na mortalidade do município. Constitui-se em uma análise de dados de registro relativos à mortalidade por causas externas para o período de 1979 a 1987, e em uma análise crítica das informações coletadas das declarações de óbito para o ano de 1987. Apresenta-se a mortalidade por causas externas da área investigada, sua magnitude e importância em relação às principais causas de morte no município, em números absolutos, proporções, coeficientes brutos e padronizados, taxas e anos de vida potencialmente perdidos, estratificados por grupos de causas externas específicas, sexo e idade. Na análise, constrói-se um perfil sócio-econômico-demográfico destas vítimas. Discute-se os resultados à luz do conhecimento sociológico e histórico da dinâmica social de Duque de Caxias. Conclui-se sugerindo algumas medidas que consideram-se de extrema necessidade para o apoio às vítimas da violência.

[Risk for injuries in traffic accidents among drivers under the effect of alcohol in Navarra]

We conducted a retrospective analysis of the levels of alcohol in the blood of a group of 54 drivers who required hospital emergency care after having suffered a traffic accident on roads in the Health Area III of Navarra (Spain) from June to September 1989, and compared them to another group of 219 drivers, not victims of traffic accidents, submitted to the breathalyser (test of alcoholaemia) on the roads of the same Health Area over the same period of time. In the group of 54 accident victims, the median alcoholaemia was 100 mg/dl, with a quartile deviation of 88 mg/dl, and the percentage of positives (alcoholaemia equal to or greater than 80 mg/dl) was 50.9%. In the group of 219 drivers not victims of traffic accidents, the median alcoholaemia was 16 mg/dl, the quartile deviation 18.5 mg/dl and the percentage of positive alcoholaemia was 1.8%. Drivers with a level of blood alcohol equal to or greater than 80 mg/dl have an estimated risk (Odds Ratio) of being injured in a traffic accident 55.82 times higher than drivers with a lower level.

Causes of death in a cohort of 50,465 young men--validity of recorded suicide as underlying cause of death

We studied causes of death in a cohort of all young males (n = 50,465) conscripted for military service in 1969-70. Six hundred eighty three deaths occurred in the cohort during the follow-up through 1983. Injury-related deaths accounted for 75% of all deaths. Of these, 38% were definite suicides, 10% undetermined suicides and 30% motor vehicle accidents. The validity of officially recorded causes of death was studied by scrutinizing all death certificates (n = 683) and forensic reports, including police reports, toxicological and histological data, from a sample (n = 322) of deaths with unclear circumstances. Of 161 officially recorded suicides (E950-959), only one case was reevaluated into poisoning, "undetermined" (E980). Of 47 cases officially recorded "undetermined" (E980-989), 9 were reevaluated into definite suicide (E950-959) although we believe that this is still an underestimation of "true" suicide cases. An alcohol concentration of more than 0.1 g% was found in 45% of all violent deaths (E800-999), 34% of all suicides and 60% of all "undetermined" deaths. We conclude that the causes of death in most cases of injury related death in young age are recorded with high accuracy. Reevaluation of recorded deaths from "undetermined" causes revealed a number of definite suicides, although the "true" number of suicides is difficult to assess even after close scrutiny of the information available.

[Mortality by external causes among residents of Barcelona (1983-1987)]

Mortality due to external causes (EC) is an increasing problem among young people in Spain, with little epidemiologic knowledge available at the small-area level in urban settings. The objective of the present study is the assessment of the magnitude and distribution of EC-related mortality among residents in Barcelona during the 1983-1987 time period. The main EC-related deaths were traffic injuries (9.3 deaths per 100,000), suicides (7.2 deaths per 100,000), and falls (6.9 deaths per 100,000). EC have been the main cause of death up to 35 years of age, contributing to 19% of the total number of years of potential life lost. Traffic-related deaths occurred mainly in the 15-24 age group for vehicle occupants (11.7 deaths per 100,000), while deaths among pedestrians occurred primarily among people older than 75 years (16.4 deaths per 100,000). The largest share of deaths due to suicide also occurred in this same group (19.6 deaths per 100,000), followed by people 25-34 years old. Expectedly, the higher death rates due to falls occurred among elderly people, older than 75 years of age (71.8 deaths per 100,000). These results indicate that patterns of mortality due to external causes in Barcelona are rather similar to those in European countries, suggesting that the strategies to achieve the prevention and control of such deaths among Barcelona residents should presumably be close to those presently being implemented in those countries.

Accidental firearm fatalities among New Mexico children

STUDY HYPOTHESIS

Risk factors associated with unintentional gunshot fatalities among children include gender and race of the decedent, type of firearm used, and whether loaded guns are stored within the home.

STUDY POPULATION

All New Mexico children 0 to 14 years old unintentionally killed by a firearm between 1984 and 1988.

METHODS

The New Mexico Office of the Medical Investigator master mortality file was reviewed retrospectively to identify all unintentional firearm fatalities occurring in New Mexico children during a five-year period. Medical investigator, autopsy, and police reports were analyzed to identify epidemiologic factors associated with these deaths. Chi-square and Fisher's exact tests were used to analyze the data.

RESULTS

Twenty-five unintentional firearm fatalities were identified. These deaths occurred most frequently among children playing with loaded firearms found within the home. A disproportionate number involved handguns.

CONCLUSIONS

The study results provide a basis for preventive strategies that limit accessibility or decrease lethality of loaded firearms within the home.