Gun Violence

AEM Early Access 21: Long-term Mortality in Pediatric Firearm Assault Survivors

Welcome to the twenty-first episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON LINK FOR FULL TEXT, OPEN ACCESS THROUGH DECEMBER 31):

Long-term mortality in pediatric firearm assault survivors: a multi-center, retrospective, comparative cohort study. Ashkon Shaahinfar, MD, MPH, Irene H. Yen, PhD, MPH, Harrison J. Alter, MD, MS, Ginny Gildengorin, PhD, Sun-Ming J. Pan, James M. Betts, MD and Jahan Fahimi, MD, MPH.

listen now: first author interview with ashkon shaahinfar md mph

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Ashkon Shaahinfar, MD, MPH

Attending Physician and Emergency Ultrasound Director

Division of Emergency Medicine

UCSF Benioff Children’s Hospital Oakland

ABSTRACT

Objectives: The objective was to determine whether children surviving to hospital discharge after firearm assault (FA) and nonfirearm assault (NFA) are at increased risk of mortality relative to survivors of unintentional trauma (UT). Secondarily, the objective was to elucidate the factors associated with long-term mortality after pediatric trauma.

Methods: This was a multicenter, retrospective cohort study of pediatric patients aged 0 to 16 years who presented to the three trauma centers in San Francisco and Alameda counties, California, between January 2000 and December 2009 after 1) FA, 2) NFA, and 3) UT. The Social Security Death Master File and the California Department of Public Health Vital Statistics (2000–2014) were queried through December 31, 2014, to identify those who died after surviving their initial hospitalization and to delineate cause of death. Multivariate Cox proportional hazards regression was performed to determine associations between exposure to assault and long-term mortality.

Results: We analyzed 413 FA, 405 NFA, and 7,062 UT patients who survived their index hospital visit. A total of 75 deaths occurred, including 3.9, 3.2, and 0.7% of each cohort, respectively. Two-thirds of all long-term deaths were due to homicide. After multivariate adjustment, adolescent age, male sex, black race/ethnicity, and public insurance were independent risk factors for long-term mortality. FA (adjusted hazard ratio [AHR] = 1.8, 95% confidence interval [CI] = 0.82–4.0) and NFA (AHR = 1.9, 95% CI = 0.93–3.9) did not convey a statistically significant difference in risk of long-term mortality compared to UT. Being assaulted by any means (with or without a firearm), however, was an independent risk factor for long-term mortality in the full study population (AHR = 1.9, 95% CI = 1.01–3.4) and among adolescents (AHR = 1.9, 95% CI = 1.01–3.6).

Conclusion: Children and adolescents who survive assault, including by firearm, have increased long-term mortality compared to those who survive unintentional, nonviolent trauma.

AEM Early Access 03: Pediatric Firearm Injuries (PECARN Network)

Welcome to the third episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and links to curated FOAMed supportive educational materials for EM learners.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Open access through July 31st:

Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network. Patrick M. Carter, MD, Lawrence J. Cook, PhD, Michelle L. Macy, MD, MS, Mark R. Zonfrillo, MD, MSCE, Rachel M. Stanley, MD, MHSA, James M. Chamberlain, MD, Joel A. Fein, MD, MPH, Elizabeth R. Alpern, MD, MSCE, and Rebecca M. Cunningham, MD, for the Pediatric Emergency Care Applied Research Network (PECARN). 

Patrick Carter, MD, Assistant Professor, University of Michigan Injury Center, Department of Emergency Medicine, University of Michigan School of Medicine

 

 

Patrick Carter, MD, Assistant Professor, University of Michigan Injury Center, Department of Emergency Medicine, University of Michigan School of Medicine

 

 

 

LISTEN NOW: Patrick Carter MD discusses this article, the public health implications of pediatric firearm injuries in the United States, and potential future directions for researchers and emergency physicians in their efforts to address the problem. 

 

ARTICLE SUMMARY:

Objective: To describe the characteristics of children seeking emergency care for firearm injuries within the PECARN network ,and assess the influence of both individual and neighborhood factors on firearm related injury risk.

Methods: Retrospective, multicenter cross-sectional analysis of children (<19 years old) presenting to 16 pediatric EDs (2004-4008).  ICD-9- CM E codes were used to identify and categorize firearm injuries by mechanism/intent.  Neighborhood variables were derived from home address data.  Multivariable analysis examined the influence of individual and neighborhood factors on firearm-related injuries compared to nonfirearm ED visits.  Injury recidivism was assessed. 

Results: A total of 1,758 pediatric ED visits for firearm-related injuries were analyzed.  Assault (51.4%, n=904) and unintentional injury (33.2%, n=584) were the most common injury mechanisms.  Among children with firearm injuries.  68.3% were older adolescents (15-19 years old), 82.3% were male, 68.2% were African American, and 76.3% received public insurances/were insured.  Extremity injuries were most common (75.9%), with 20% sustaining injuries to multiple body regions, 48.1% requiring admission and 1% ED mortality.  Multivariable analysis identified firearm injury risk factors, including adolescent age (p < 0.001), male sex (p < 0.001), non-Caucasian race/ethnicity (p<0.001), public payer/uninsured status (p<0.001), and higher levels of neighborhood disadvantage (p<0.001).  Among children with firearm injuries, 12 month ED recidivism for any reason was 22.4%, with < 1 % returning for another firearm injury.

Conclusion: Among children receiving ED treatment within the PECARN network, there are distinct demographic and neighborhood factors associated with firearm injuries.  Among younger children (<10 years old), unintentional injuries predominate while assault-type injuries were most common among older adolescents.  Overall, among this PECARN patient population, male adolescents living in neighborhoods characterized by high levels of concentrated disadvantage had an elevated risk for firearm injury.  Public health efforts should focus on developing and implementing initiatives addressing risk factors at both the individual and the community level including ED-based interventions to reduce the risk for firearm injuries among high-risk pediatric populations.

 

RELATED #FOAMED EDUCATIONAL RESOURCES:

Firearm Related Injury and Death in the United States: A Call to Action Annals of Internal Medicine, April 7 2015 (open access)

Ped EM Morsels: Gun Safety

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-Analysis, Annals of Internal Medicine, January 21 2014 (open access)

Should Physicians Ask About Guns? Clinical Correlations 4/11/14

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research, Megan Ranney MD et al, Annals of Emergency Medicine, February 2017 

Subscription only: EMRAP April 2015. The Poetry of Emergency Medicine: Gun Violence