Points of Influence for Lethal Means Counseling and Safe Gun Storage Practices. Runyan CW, Brooks-Russell A, Betz ME. J Public Health Manag Pract. Jan/Feb 2019;25(1):86-89.
Firearm-related mortality remains a hot topic in traumatic injury prevention. Much focus has been placed on interpersonal violence; however, deaths by suicide significantly outnumber all others from homicide or negligent discharges. Suicide attempts are far more likely to be successful when performed with a firearm compared to other means. This together with the knowledge that suicide attempts are often acted on out of impulse and not repeated, safe storage around at-risk individuals is a crucial component of firearm-related suicide prevention. This manuscript presents opportunities to effectively advocate for evidence-based patient counseling about lethal means and expand safe storage options to mitigate suicide risk.
Patient counseling on firearm lethality and safe storage is recommended by many national organizations to address suicide prevention. However, the article reports that less than half of patients in the emergency department (ED) with suicide risk received counseling on lethal means. Standardization of and training on counseling protocols for those who screen positive for suicide risk may improve delivery rates. Those who are interested in implementing such protocols are recommended to engage nursing leadership and mental health providers to advocate and direct development.
Temporary out-of-home firearm storage is an excellent option for at-risk individuals during times of crisis. A survey revealed that 70% of law enforcement agencies and nearly half of firearm retail shops offer temporary storage. Suicide-prevention advocacy should involve influential stakeholders to be most effective. The article suggest that this includes The Joint Commission, mental health professionals, ED physicians, the American College of Emergency Physicians, local law enforcement, the National Rifle Association, and the National Shooting Sports Foundation. The message to these organizations should center around the public health impact of suicide, the impulsivity of the act, and the lethality of using a firearm to improved counseling and safe storage options. Potential barriers such as cost, space, and legal risk must be addressed. The approach to patient counseling should include opening respectful dialogue of the impartial evidence of risk and mitigation. Through advocacy to expand patient counseling and out-of-home safe storage options, meaningful impact on firearm-related suicide deaths may be made.
Assessing the impact of blood alcohol concentration on the rate of in-hospital mortality following traumatic motor vehicle crash injury: A matched analysis of the National Trauma Data Bank. Ahmed N, Greenberg P. Injury. 2019;50(1):33-38.
The known effects of alcohol concentration on the mental and physical ability of motor vehicle drivers and its associated risk factor for car crash mortalities has been extensively studied. In 2015, it was reported that nearly 30% of all traffic related deaths were due to alcohol consumption. Further evidence suggests that blood alcohol concentration (BAC) drivers were more likely to be traveling at a higher rate of speed and in consequence can lead to higher impact accidents with associated injury severity scores (ISS) and mortality. This manuscript presented an opportunity for the authors to use the US National Trauma Data Bank (NTDB) to compare the in-hospital mortality rates of pair-matched BAC positive and negative patients.
Any injured patient in the NTDB from 2007-2020 who were >14 years of age and sustained a traumatic injury while driving were evaluated. Patients were divided into two groups based on their BAC at arrival to the trauma center. The two groups included “alcohol negative group” while patients with positive results beyond the legal limit of 0.08 g/dL were in the “alcoholic positive group.” The primary outcomes were in- hospital mortality with secondary outcomes being total length of hospital stay, time to patient expiration, and discharge disposition.
In the study about 30% of the patients tested positive for alcohol with a BAC at or above the legal limit. With that being said, there was no evidence of a significant difference in the rate of in-hospital mortality, the time to patient expiration, or discharge disposition among those who survived to discharge regardless of whether the patient had a positive or negative BAC at the time of admission. The average age of the patients was around 33 years, and they found no clinical evidence in difference with regards to ISS. Although there were no reported differences in mortality, consuming 5 or more alcoholic drinks including 12 oz. of beer, 5 oz. of wine, or 1.5 oz. of hard liquor over a short time can lead to alcohol intoxication above the legal limit leading to impaired driving which can result in fatal accidents. In this manuscript various cited studies had shown that motor vehicle crash patients with acute intoxication are two times more likely to have higher severity head injuries. Although this study was a NTDB study with more than 50,000 patients from all over the United States that had propensity score and exact matching methods to remove potential selection bias, there was no clinical difference between the patient populations in respect to outcomes. The study does discuss possible limitations including a large retrospective database with missing values and missing injury related information.
Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After A fall: A Randomized Clinical Trial. Liu-Ambrose T, Davis JC, Best JR, et al. [published correction appears in JAMA. 2019 Jun 4;321(21):2092-2100.
While a fall is the third most common cause of disability in the elderly, the best method for lessening falls in this population is unknown. Previous research has not shown that exercise lessens falls in the elderly. This trial is a randomized clinical trial examining the effect of the Otago Exercise Program on fall prevention.
The Otago Exercise Program includes multiple strength exercises and balance retraining exercises. Participants were randomized to usual care or the Otago Exercise Program in addition to usual care. This program was individualized by a physical therapist in the home for community-dwelling elderly adults over the age of 70 years. These participants had a fall in the last year and a high risk of future falls by one of multiple criteria. Five total physical therapist visits occurred over 6 months. The study subjects did the exercises three times weekly and walked at least twice weekly for 30 minutes. Falls were the primary outcome.
Mean age was 81 years in both groups. Adherence to the strength/balance program was 63% and the walking program was 127%. Number of falls was significantly lower with the exercise program and usual care (1.4 falls/person-year) compared with just usual care (2.1 falls/person-year), although there was a similar percentage of participants with falls with the exercise program and usual care (61%) compared with just usual care (60%). Similar numbers of fall-related fractures were seen with the exercise program and usual care when compared with just usual care, and there was no significant difference in the time to first fall between groups.
The addition of the Otago Exercise Program for community-dwelling elderly adults decreased the number of falls for elderly adults. While there was not a significant effect of the exercise program for number of participants who fell or time to first fall, the study was felt successful because of the decrease in the fall quantity.
Article 4 Baltimore Ceasefire 365: Estimated Impact of a Recurring Community-Led Ceasefire on Gun Violence.
Phalen P, Bridgeford E, Gant L, Kivisto A, Ray B, Fitzgerald S. Am J Public Health
Firearm violence has been a major challenge in Baltimore, which has one of the highest homicide rates of any major city in the U.S. Beginning in 2017, community members in Baltimore declared a Ceasefire weekend, with the straightforward statement “nobody kill anybody” from Friday through Sunday. Subsequently, weekends have occurred quarterly. Public events, social media, conventional media, and word of mouth are used to advertise the weekends. Events during the weekends have included rallies, vigils, parties, and resource fairs. Organizers also hold intermittent public events between weekends. Using multilevel poisson regression models controlling for day of week, seasonality, and holidays, the researchers found an impressive 53% reduction in shootings on Ceasefire weekends (95% CI 33-67%). They evaluated for a postponement effect but found no higher rates of violence in surrounding days or weeks.
With firearm violence rising this summer in many cities across the U.S., the need for innovative violence prevention strategies is more apparent than ever. While the true impact of COVID-19 and related policies on violence is unknown, social distancing has reduced positive community presence in public spaces, perhaps leaving more openings for violence. The Baltimore Ceasefire weekends present a powerful example of the opposite: the role that strong community presence can play in reducing violence. This study also serves as an excellent example of community-engaged research. The intervention was designed and carried out by community organizers, who were also included in the research team and author list. Other authors brought appropriately sophisticated methods to perform a rigorous evaluation.
These results speak to the power and potential of community driven violence prevention, but it remains unclear whether a similar strategy used more frequently could produce a sustained reduction in violence year-round. The major strengths of this intervention are its local focus and community engagement, but this means that replication might not achieve the same results elsewhere.