Article 1
Defining the Full Spectrum of Pediatric Firearm injury and Death in the United States: It is Even Worse Than We Think. Naik-Mathuria BJ, Cain CM, Alore EA, Chen L, Pompeii LA. Ann Surg. 2023 Jul 1;278(1):10-16.
This is a cross-sectional study combining fatal injury data from the Centers for Disease Control (CDC) and nonfatal injury data from the National Trauma Data Bank (NTDB), 2008-2019, for victims 0-17 years old. The authors start by making a reasonable case for this choice of data – while their claim that nonfatal injury data is “no longer reported” by the CDC is not entirely correct, it is true that many subsets (e.g., some intents, demographic subsets, years or combinations thereof) are not reported due to unstable estimates. Thus, fatal injury data from the CDC was combined with nonfatal injury from the NTDB. They found an average rate of approximately 4600 shootings per year in this age group, about a third of which were fatal each year. The majority of victims were male (84%), 15-17 years old (76%), and Black (rate: 49.43 per million vs 15.76 per million white non-Hispanic). Assault/homicide was the most common intent among both nonfatal (72%) and fatal (56%) injuries, but self-harm had the highest case-fatality rate (84%). Suicide was more common than homicide in the 12-14 year-old subset, but homicide was more common among 15-17 year-olds. Unintentional nonfatal injury was slightly more common than nonfatal assault in the <12 year-old group (48% vs 44%). 75% of suicide attempts (nonfatal + fatal) were in white, non-Hispanic children, while Black children were 10.5 times more likely to be killed by assault and 25.5 times more likely to be injured by assault than white non-Hispanic children. Firearm injury was more common in the South and Midwest. Regarding temporal trends, the authors note a decrease through 2014, followed by an increase 2015-2017, and a slight decrease through 2019.
The main strength of this study is the inclusion of nonfatal injuries, which are often overlooked. In the Discussion, it is noted that prior studies have attempted to do this using other data, but these authors believe NTDB to be the most comprehensive. The inclusion of nonfatal injury uncovers important results, including a significant rate of unintentional injury (15% of firearm injuries in this age group), which might be underappreciated when solely fatal injuries are examined given a low case-fatality rate. Downsides include the fact that the NTDB is not a validated surveillance system and only includes centers by voluntary participation; the lack of poverty or other socioeconomic variables in the data; and the lack of data beyond 2019, which would include a significant and well-documented increase in firearm violence during the COVID-19 pandemic.
Article 2
Patient-reported outcomes at 6 to 12 months among survivors of firearm injury in the United States. Herrera-Escobar JP, de Jager E, McCarty JC, Lipsitz S, Haider AH, Salim A, Nehra D. Ann Surg. 2021 Dec 1;274(6):e1247-e1251.
While most firearm injury victims survive, few studies have evaluated the long term physical and psycho-social burden of their injuries. To some extent, this is due to limitations in the collection of such data. The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project registry provides such an opportunity. This database prospectively collects post-discharge patient reported outcomes across three level one trauma centers in Boston, Massachusetts. Access to individual charts is also granted.
Herrera-Escobar et al used FORTE data from 2015-2018 and captured survey responses from shooting victims with an ISS of 9 or greater at 6 and 12 months. These victims were compared to known population averages and were also matched to 255 motor vehicle crash (MVC) survivors from the same dataset. This matching was based upon a Coarsened Exact Matching (CEM) technique using age, sex, race, education and pre-existing psychiatric illness. A CEM weighted generalized linear model was then used adjusted for ISS, substance use disorder and discharge disposition.
Outcome measures included post traumatic stress disorder (PTSD) using the Breslau questionnaire, functional limitations using the T-QoL tool to assess for any new need for assistance, return to work after injury and physical and mental health quality of life using the Short-Form 12 (SF-12) Health Survey.
63 shooting victims participated in the study. They no significant demographic differences from non-participants. Of these survivors, 68% reported daily pain, 53% screened positive for PTSD, 39% had a new functional limitation and 59% of previously working victims had not returned to work. Physical and mental health-related quality of life was significantly worse for shooting survivors than known average scores of the general population.
When compared to the matched cohort of MVC survivors, shooting survivors had a longer hospital length of stay, intensive care unit length of stay and a higher prevalence of substance use disorder. Other factors, such as ISS, age, race and procedures were not different. Shooting victims were more likely to report daily pain (aOR 3.1, 95% CI 1.3 to 7.6), screen positive for PTSD (aOR 2.5, 95% CI 1.1 to 5.8) and had worse physical and mental health quality of life scores. The mean score difference (shooting victim versus MVC survivor) for the SF-12 Mental Component Score (MCS) was -6.7 (95% CI -12.5 to -1.1) and for the SF-12 Physical Component Score (PCS) it was -5.1 (95% CI -9.3 to -0.9). However, return to work and new functional limitations were not significantly different.
The authors conclude that survivors of firearm injuries have worse long term outcomes than MVC survivors and worse quality of life than the general public. They suggest targeted screening and long term follow up care addressing the physical and mental health needs of shooting survivors.
Article 3
A novel machine-learning tool to identify community risk for firearm violence: The Firearm Violence Vulnerability Index. Polcari AM, Hoefer LE, Zakrison TL, Cone JT, Henry MC, Rogers SO, Slidell MB, Benjamin AJ. J Trauma Acute Care Surg. 2023 Jul 1;95(1):128-136.
The study introduces a novel machine learning model, the Firearm Violence Vulnerability Index (FVVI), crafted to predict firearm violence in U.S. urban areas. Gun violence data along with 30 other population characteristics from Baltimore, Boston, Cincinnati, Los Angeles, New York City, Philadelphia, and Rochester were used to train the model. The model was then validated on data from Chicago. Results of this showed that FVVI accurately predicted shooting incidents in Chicago, whose population characteristics are largely significantly different than the training cohort's, in addition to being geographically distinct as well. The goodness of fit, from calculated D2, was 0.77. FVVI decile scores, from 0.1-1, predict the amount of shootings per 1000 persons. For example, a FVVI decile of 0.1 predicts 1.13, where 0.7 predicts 8.81.
This model is first of its kind in providing such detailed risk forecasting using population characteristics which are publicly available from the U.S. census bureau. It has several potential uses. First in violence prevention programs in cities where there is not robust public reporting of gun violence data, this model can be used to help focus efforts. Secondly, it can be used to model the potential effect of interventions on firearm violence, by manipulating the input population characteristics.
Article 4
Suicide versus homicide firearm injury patterns on trauma systems in a study of the National Trauma Data Bank (NTDB). Foote CW, Doan XL, Vanier C, Cruz B, Sarani B, Palacio CH. Sci Rep. Sep 19;12(1):15672.
Mortality rates secondary to firearms injuries in the United States are greatest among all high-income countries. While these deaths have decreased in most of these countries, the United States has witnessed the opposite trend. Intentional firearm-related deaths are within the top ten causes of injury deaths in the United States, and lead to almost 15% of years of potential life lost before the age of 65.
Foote et al. performed a retrospective study using the American College of Surgeons (ACS) National Trauma Data Bank (NTDB) to evaluate intentional firearm injuries, comparing “suicide” and “homicide” groups from January 2017 to December 2019. The authors used the Mann-Whitney test, Fisher’s exact test, and Logistic regression to compare demographics, injury severity, weapon type, mortality and other characteristics between the groups. 100,031 homicides and 11,714 were identified during the defined study period. The median age of the suicide group (36, IQR: 19,54) was older than the homicide group (20, IQR: 14,30). White subjects comprised 78.9% of the suicide group and African American subjects comprised 62% of the homicide group. Abbreviate Injury Scare (AIS) Scores were higher in the suicide group (5, IQR: 3,5) compared to the homicide group (3, IQR: 2,3) along with a higher frequency of a Glasgow Coma Scale (GCS) less than 13 (19.9 % vs 4.2%). The suicide group had a higher odds of being free of illicit substances upon admission (OR 2.27, 95% CI 2.16 - 2.39). The suicide group had higher rates of head or neck injury (67% vs 13%) while the homicide group had higher rates of extremity injury (34% vs 7%). In-hospital mortality was significantly higher in the suicide group (OR=6.2, p<0.001).
This study confirms important differences between two groups experiencing intentional firearm injury. Younger African-American males within urban centers tend to compose “homicide” groups, while older White males within rural settings compose “suicide” groups. This reaffirms the influence of social determinants of health on this problem and the need for targeted interventions on modifiable risk factors. Further, patients within the “suicide” group experience higher rates of head and neck injury while those within the “homicide” group experience higher rates of extremity injury, highlighting the clinical differences upon presentation. A notable limitation of the study was not evaluating the presence of ethanol between the two groups, which has a documented association with intentional injuries.
