'It's changed how we have these conversations': emergency department clinicians' experiences implementing firearms and other lethal suicide methods counseling for caregivers of adolescents

Counseling parents to reduce access to firearms and other potentially lethal suicide methods is commonly known as lethal means counseling (LMC). The current study explores the experiences that emergency department-based behavioural health clinicians described having as they provided lethal means counseling to parents of adolescents at risk for suicide. Clinicians were purposively sampled from four hospital networks in Colorado after their hospitals adopted LMC protocols as part of an intervention that also included online training in LMC and provision of free medication and firearm lockboxes. Twenty-three clinicians were interviewed using semi-structured interviews. Data were analysed using a modified grounded theory-based approach. Clinicians felt more comfortable and effective in their abilities to provide LMC after the intervention. Clinicians also described how being able to offer free storage devices helped them engage in LMC. In advising parents to make guns and medications inaccessible to their at-risk child, most clinicians pointed to at least one of three research findings highlighted in the online training: (1) Suicide attempts with guns rarely afford second chances, (2) medication overdoses can kill, (3) suicidal behaviour is always unpredictable and often impulsive. All clinicians described a desire to continue LMC as currently protocolized at their hospital after the study ended.

A population based study of unintentional firearm fatalities

OBJECTIVES

To describe the circumstances of fatal unintentional firearm injuries in a statewide population in a region of the United States with high firearm fatality rates and to compare to similar data from an earlier period in the same state.

METHODS

Analyses of North Carolina medical examiner database (1985-94) and review of medical examiner case reports (1990-94) and comparison to similar data from 1979-82.

RESULTS

A total of 390 unintentional shooting deaths occurred (0.59/100,000 population) between 1985-94 with the highest rate in the ages 15-24. Between 1990-94, handguns were responsible for 59% of these deaths compared to 40% in the 1979-82 period. Younger victims were more likely to be shot by family or friends, though, 53% of all deaths were self inflicted. In 45 cases, the person firing the weapon was reported to believe that the gun was unloaded or had the safety device activated.

CONCLUSIONS

This study demonstrates changes in patterns of unintentional firearm fatalities in North Carolina in two decades, particularly the increase in incidence of events involving handguns. The results highlight the need for additional attention to efforts governing access to firearms, particularly handguns; technological advances in designing safer guns, and additional emphasis on safe storage policies and practices.

Sex steroids and the endothelium

Gonadal steroids clearly influence the course of atherosclerotic cardiovascular disease in women. This observation has suggested that these hormones have beneficial effects on the physiology of the vascular wall. Increased arterial vascular caliber after estrogen treatment, decreased lipid levels in subjects receiving hormone replacement therapy, and the markedly decreased extent of atherosclerotic plaque formation in young women as compared with young men support a cardioprotective effect of ovarian steroids. Generally, it appears that the effects of 17beta-estradiol are particularly beneficial, and the mechanism of action is targeted largely to the endothelial cell. This review describes the evidence for positive effects of estrogens on endothelial cell biology and considers potential mechanisms for estrogen actions on endothelial cell signal transduction.

Flavonoids as DNA topoisomerase antagonists and poisons: structure-activity relationships

Selected flavonoids were tested for their ability to inhibit the catalytic activity of DNA topoisomerase (topo) I and II. Myricetin, quercetin, fisetin, and morin were found to inhibit both enzymes, while phloretin, kaempferol, and 4',6,7-trihydroxyisoflavone inhibited topo II without inhibiting topo I. Flavonoids demonstrating potent topo I and II inhibition required hydroxyl group substitution at the C-3, C-7, C-3', and C-4' positions and also required a keto group at C-4. Additional B-ring hydroxylation enhanced flavonoid topo I inhibitory action. A C-2, C-3 double bond was also required, but when the A ring is opened, the requirement for the double bond was eliminated. Genistein has been previously reported to stabilize the covalent topo II-DNA cleavage complex and thus function as a topo II poison. All flavonoids were tested for their ability to stabilize the cleavage complex between topo I or topo II and DNA. None of the agents stabilized the topo I-DNA cleavage complex, but prunetin, quercetin, kaempferol, and apigenin stabilized the topo II DNA-complex. Competition experiments have shown that genistein-induced topo II-mediated DNA cleavage can be inhibited by myricetin, suggesting that both types of inhibitors (antagonists and poisons) interact with the same functional domain of their target enzyme. These results are of use for the selection of flavonoids that can inhibit specific topoisomerases at specific stages of the topoisomerization reaction.

The dietary anticancer agent ellagic acid is a potent inhibitor of DNA topoisomerases in vitro

Ellagic acid and 12 related agents have been tested for their ability to inhibit the activities of human DNA topoisomerase (topo) I and II. Using specific in vitro assays, we found ellagic acid and flavellagic acid to be potent inhibitors of the catalytic activities of the two topoisomerases. The minimum concentration required to inhibit > or = 50% of catalytic activity (IC50) of ellagic acid was determined at 0.6 and 0.7 micrograms/ml for topo I and topo II, respectively. Flavellagic acid's IC50 was determined at 3.0 and 3.6 micrograms/ml for topo I and topo II, respectively. Unlike topoisomerase poisons, these two plant phenols did not trap the enzyme-DNA reaction intermediate, known as the cleavable complex. In contrast, ellagic acid prevented other topo I and topo II poisons from stabilizing the cleavable complex, suggesting that the mode of its action is that of an antagonist. Structure-activity studies identified the 3,3'-hydroxyl groups and the lactone groups as the most essential elements for the topoisomerase inhibitory actions of plant phenols. On the basis of these findings and other properties of ellagic acid, a mechanistic model for the documented anticarcinogenic effects of the agent is proposed.

Adolescent abuse: the dimensions of the problem

Physical and sexual abuse of adolescents is becoming a major health problem in the United States. Among all confirmed cases of abuse, 28% occur between 12 and 17 years of age. Physical abuse in this age group often results from situational conflicts and discipline is frequently the rationale. In infants the sex distribution is approximately equal, but adolescent females are twice as likely to be abused as adolescent males, largely because of the frequency of sexual abuse. As the individual of first contact, the health care provider is often in a unique position to offer help to both the adolescents and their parents by maintaining open lines of communication, relating to the parents and the youth, diffusing potentially abusive situations, and treating cases appropriately when abuse occurs. This paper reviews the Minnesota definitions of abuse and neglect and presents recent Minnesota data on adolescent abuse. The dynamics of the problem are analyzed in comparison with child abuse and in the context of adolescent development. Suggestions are presented to assist the practitioner in identifying, treating and reporting adolescent abuse.