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Caregivers face challenges when trying to prevent injury, respect autonomy, and avoid conflict in the care of community-dwelling persons with dementia who have access to firearms. This randomized trial examines the effectiveness of "Safety in Dementia," an online decision aid to assist caregivers' decisions about firearm access for persons with dementia who are under their care. Visual Abstract. The Effect of the "Safety in Dementia" Online Tool to Assist Decision Making for Caregivers of Persons With Dementia and Access to Firearms: Caregivers face challenges when trying to prevent injury, respect autonomy, and avoid conflict in the care of community-dwelling persons with dementia who have access to firearms. This randomized trial examines the effectiveness of "Safety in Dementia," an online decision aid to assist caregivers' decisions about firearm access for persons with dementia who are under their care. Background: Caregivers face challenges (including competing desires to prevent injury, respect autonomy, and avoid conflict) when addressing firearm access by community-dwelling persons with Alzheimer disease and related dementias (ADRD). Objective: To test the effect of the online Safety in Dementia (SiD) decision aid on caregivers' decision making about firearm access for people with ADRD. Design: Prospective 2-group randomized trial with longitudinal follow-up. (ClinicalTrials.gov: NCT05173922) Setting: United States. Participants: English- or Spanish-speaking caregivers (aged ≥18 years) of community-dwelling adults with ADRD and firearm access. Intervention: SiD versus a web-based information control. Measurements: The primary outcome was preparation for decision making about firearm access. The secondary outcome at follow-up was self-reported action to reduce access. Results: Among 500 participants enrolled between June 2022 and February 2024, the mean age was 47 years, 69% identified as female, half were the adult child or stepchild of the person with ADRD, and 99% chose study participation in English. Participant characteristics were similar by study group. For the primary outcome, SiD significantly increased preparation for decision making versus the control (69.8 vs. 64.8 out of 100; mean difference, 4.80 [95% CI, 0.53 to 9.07]; P = 0.024). There was no significant effect on actions to reduce firearm access at 2 weeks or 2 months. Limitation: The results may not be generalizable to non–English-speaking populations. Conclusion: The online SiD decision aid increased preparation for decision making about firearm access in this sample of ADRD caregivers in the United States. Use of such resources in clinical or community settings may support caregivers and people with ADRD in avoiding firearm injury or death. Primary Funding Source: National Institute on Aging, National Institutes of Health. [ABSTRACT FROM AUTHOR]

Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States. This study examines the factors associated with recurrent firearm injury among children who presented with a nonfatal firearm injury in the St. Louis, Missouri, region. Visual Abstract. Factors Associated With Recurrent Pediatric Firearm Injury: Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States. This study examines the factors associated with recurrent firearm injury among children who presented with a nonfatal firearm injury in the St. Louis, Missouri, region. Background: Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States. Objective: To examine the factors associated with recurrent firearm injury among children who presented with acute (index) nonfatal firearm injury in the St. Louis region. Design: Multicenter, observational, cohort study. Setting: 2 adult and 2 pediatric level I trauma hospitals in St. Louis, Missouri. Participants: Pediatric patients aged 0 to 17 years presenting with an index firearm injury between 2010 and 2019. Measurements: From the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, we collected data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and mortality. The Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the cumulative incidence of experiencing a recurrent firearm injury. Results: During the 10-year study period, 1340 children presented with an index firearm injury. Most patients were Black (87%), non-Hispanic (99%), male (84%), and between the ages of 15 and 17 years (67%). The estimated risk for firearm reinjury was 6% at 1 year and 14% at 5 years after initial injury. Male children and those seen at an adult hospital were at increased risk for reinjury. Limitation: Our data set does not account for injuries occurring outside of the study period and for reinjuries presenting to nonstudy hospitals. Conclusion: Children who experience an initial firearm injury are at high risk for experiencing a recurrent firearm injury. Interventions are needed to reduce reinjury and address inequities in the demographic and clinical profiles within this cohort of children. Primary Funding Source: National Institutes of Health. [ABSTRACT FROM AUTHOR]

Background: Low-income pregnant patients are at high risk of postpartum depression (PPD). Mothers and Babies (MB) is a cognitive behavioral therapy–based program that prevents up to 50% of de novo PPD when provided in person to low-income Spanish- and English-speaking people who are pregnant without depression. MB is limited by the need for trained personnel to support it. Transforming MB into a smartphone app may mitigate this key barrier. Objective: We aimed to use qualitative data from target end users to create and optimize MBapp, a novel app centered on the MB program. Methods: Draft wireframes of MBapp were created in English and Spanish with cognitive behavioral therapy–based modules adapted from MB. These wireframes included several features shown previously to sustain app engagement: (1) push notifications delivered at participant-preferred times; (2) text-, graphic-, and video-based content; and (3) gamification with digital rewards for app engagement. English- or Spanish-speaking individuals with public health insurance who were between 32 weeks gestation and 6 months post partum and owned smartphones were eligible to consent for individual in-depth interviews. Individuals with prior or current depression were excluded. Interviews were recorded, transcribed, and analyzed using deductive and inductive codes to characterize opinions about MBapp and perceptions of challenges and facilitators of use of MBapp or other perinatal or mental health apps. End user feedback led to major modifications to the wireframes. Each of these changes was categorized according to the FRAME (Framework for Modification and Adaptation), an established method of systematically reporting adaptations and modifications to evidence-based interventions via end user feedback. Recruitment ceased with content saturation, defined as 3 successive participants providing only positive feedback on MBapp's wireframe, without further suggestions for improvement. Results: A total of 25 interviews were completed. Participants were racially and ethnically diverse, generally representing our target end user population, and 48% (n=12) of interviews were conducted in Spanish. Participants' suggestions to improve MBapp were categorized within the FRAME as adaptations that improved either content or context to optimize reach, retention, engagement, and fit for end users. Specifically, the following features were added to MBapp secondary to end user feedback: (1) audio narration; (2) "ask a clinician" nonurgent questions; (3) on-demand module summaries accessible upon module completion; and (4) choice to defer assessments and start the next module. Participants also provided insights into features of perinatal or mental health apps they found appealing or unappealing to understand preferences, challenges, and negotiables or nonnegotiables for MBapp. Conclusions: Adapting MBapp to incorporate end users' perspectives optimized our digital PPD prevention intervention, ideally increasing its appeal to future users. Our team's next steps will confirm that MBapp is a feasible, acceptable intervention among English- and Spanish-speaking perinatal people at risk of PPD. [ABSTRACT FROM AUTHOR]

Background: Nearly two million adults in the US currently live with an Opioid Use Disorder (OUD) diagnosis. Recent efforts have encouraged and facilitated widespread adoption of empirically supported medications for opioid use disorder (MOUD), yet MOUD and OUD behavioral health interventions remain dramatically underutilized. Fear of discrimination and judgment, compounded by systemic and regulatory barriers, hinder individuals' access to specialty treatment.Objectives: The goal of the current study was to (1) reveal how perspectives toward OUD treatment may differ across medication types, program settings, and drug use history; (2) address systemic and regulatory components that potentially foster and propagate positive or negative attributions to OUD; and (3) understand how experiences reduce patients' willingness to pursue and/or maintain long term treatment.Methods: Twenty-four adults engaged in buprenorphine treatment at two outpatient addiction treatment centers participated in in-depth, qualitative interviews between 2019 and 2020 in Providence, Rhode Island.Results: Thematic analysis revealed negative attributions toward OUD across all participants. Three key themes developed from the coding and analysis: (1) differential perceptions of therapeutic medications (2) negative perceptions of treatment programs and (3) perceptions of drugs and people who use drugs.Conclusions: Stigmatizing language remains a major public health issue that needs to be addressed to facilitate treatment for individuals for OUD and other drug use disorders. Incorporating strategies targeting labeling across medication types, program settings, and drug use may improve treatment outcomes by reducing the inaccurate beliefs surrounding OUD and connecting patients to evidence-based support. [ABSTRACT FROM AUTHOR]

Background: Emergency care workforce concerns have gained national prominence given recent data suggesting higher than previously estimated attrition. With little known regarding characteristics of physicians leaving the workforce, we sought to investigate the age and number of years since residency graduation at which male and female emergency physicians (EPs) exhibited workforce attrition. Methods: We performed a repeated cross‐sectional analysis of EPs reimbursed by Medicare linked to date of birth and residency graduation date data from the American Board of Emergency Medicine for the years 2013–2020. Stratified by gender, our primary outcomes were the median age and number of years since residency graduation at the time of attrition, defined as the last year during the study time frame that an EP provided clinical services. We constructed a multivariate logistic regression model to examine the association between gender and EP workforce attrition. Results: A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5–65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0–53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82–2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post–residency graduation times in the workforce of 17.5 (9.5–25.5) years and 10.5 (5.5–18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation. Conclusions: Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce. [ABSTRACT FROM AUTHOR]

Background: Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention. Objective: To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life. Methods: Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873). Results: The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress. Discussion: The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone. [ABSTRACT FROM AUTHOR]

Firearm injuries are a public health crisis in the United States. Using the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, this study examined the incidence and factors associated with recurrent firearm injuries and death among patients following an acute, nonfatal firearm injury. Visual Abstract. Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019: Firearm injuries are a public health crisis in the United States. Using the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, this study examined the incidence and factors associated with recurrent firearm injuries and death among patients following an acute, nonfatal firearm injury. Background: Firearm injuries are a public health crisis in the United States. Objective: To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury. Design: Multicenter, observational, cohort study. Setting: Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019. Participants: Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury. Measurements: Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury. Results: We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years. Limitations: Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals. Conclusion: Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence. Primary Funding Source: Emergency Medicine Foundation–AFFIRM and Missouri Foundation for Health. [ABSTRACT FROM AUTHOR]

This qualitative study examines how youth and adult members of 4‐H Shooting Sports clubs perceive firearm injury risk and risk reduction, and the applicability of a bystander intervention (BI) risk reduction framework in this community. Semistructured interviews were conducted with 11 youth and 13 adult members of 4‐H Shooting Sports clubs across nine US states from March to December of 2021 until thematic saturation was reached. Deductive and inductive thematic qualitative analyses were performed. Six overarching themes emerged: (1) The tendency to view firearm injury as predominantly unintentional in nature; (2) Acknowledgment of a wide array of risks for firearm injury; (3) Perceived barriers to bystander action to prevent firearm injury including knowledge, confidence, and consequences of action; (4) Facilitators of bystander action including a sense of civic responsibility; (5) Direct and indirect strategies to address potential risks for firearm injury; and (6) Belief that BI skills training would be useful for 4‐H Shooting Sports. Findings lay the groundwork for applying BI skills training as an approach to firearm injury prevention in 4‐H Shooting Sports, similar to how BI has been applied to other types of injury (i.e., sexual assault). 4‐H Shooting Sports club members' sense of civic responsibility is a key facilitator. Prevention efforts should attend to the broad array of ways in which firearm injury occurs, including suicide, mass shootings, homicide, and intimate partner violence, as well as unintentional injury. [ABSTRACT FROM AUTHOR]

Introduction: During the COVID-19 pandemic, as society struggled with increasing disease burden, economic hardships, and with disease morbidity and mortality, governments and institutions began implementing stay-at-home or shelter-in-place orders to help stop the spread of the virus. Although wellintentioned, one unintended adverse consequence was an increase in violence, abuse, and neglect. Methods: We reviewed the literature on the effect the pandemic had on domestic violence, child and elder abuse and neglect, human trafficking, and gun violence. In this paper we explore common themes and causes of this violence and offer suggestions to help mitigate risk during ongoing and future pandemics. Just as these forms of violence primarily target at-risk, vulnerable populations, so did pandemic-related violence target marginalized populations including women, children, Blacks, and those with lower socioeconomic status. This became, and remains, a public health crisis within a crisis. In early 2021, the American College of Emergency Physicians (ACEP) Public Health and Injury Committee was tasked with reviewing the impact the pandemic had on violence and abuse as the result of a resolution passed at the 2020 ACEP Council meeting. Conclusion: Measures meant to help control the spread of the COVID-19 pandemic had many unintended consequences and placed people at risk for violence. Emergency departments (ED), although stressed and strained during the pandemic, remain a safety net for survivors of violence. As we move out of this pandemic, hospitals and EDs need to focus on steps that can be taken to ensure they preserve and expand their ability to assist victims should another pandemic or global health crisis develop. [ABSTRACT FROM AUTHOR]

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments--communicable diseases, noncommunicable conditions, and injuries--and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes. [ABSTRACT FROM AUTHOR]

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments--communicable diseases, non-communicable conditions, and injuries--and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes. [ABSTRACT FROM AUTHOR]

Introduction: During the COVID-19 pandemic, as society struggled with increasing disease burden, economic hardships, and with disease morbidity and mortality, governments and institutions began implementing stay-at-home or shelter-in-place orders to help stop the spread of the virus. Although well-intentioned, one unintended adverse consequence was an increase in violence, abuse, and neglect. Methods: We reviewed the literature on the effect the pandemic had on domestic violence, child and elder abuse and neglect, human trafficking, and gun violence. In this paper we explore common themes and causes of this violence and offer suggestions to help mitigate risk during ongoing and future pandemics. Just as these forms of violence primarily target at-risk, vulnerable populations, so did pandemic-related violence target marginalized populations including women, children, Blacks, and those with lower socioeconomic status. This became, and remains, a public health crisis within a crisis. In early 2021, the American College of Emergency Physicians (ACEP) Public Health and Injury Committee was tasked with reviewing the impact the pandemic had on violence and abuse as the result of a resolution passed at the 2020 ACEP Council meeting. Conclusion: Measures meant to help control the spread of the COVID-19 pandemic had many unintended consequences and placed people at risk for violence. Emergency departments (ED), although stressed and strained during the pandemic, remain a safety net for survivors of violence. As we move out of this pandemic, hospitals and EDs need to focus on steps that can be taken to ensure they preserve and expand their ability to assist victims should another pandemic or global health crisis develop. [ABSTRACT FROM AUTHOR]

Background: Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The "Safety in Dementia" (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown. Objective: Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access. Methods: The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost. Results: The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled. Conclusions: The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic provided a unique opportunity to examine social media and technology use during a time in which technology served as adolescents' primary form of socialization. The literature is mixed regarding how increased screen time during this period affected adolescent mental health and well-being. The mechanisms by which screen time use affected adolescent psychosocial outcomes are also unknown. Objective: We aimed to deepen our understanding of how social media and technology use, social connectivity, and emotional well-being intersected during pandemic-related school closures. Methods: English-speaking adolescents aged 13 to 17 years were recruited on Instagram for a brief screening survey; 39 participants were purposefully selected to complete a semistructured interview regarding their social media and technology use during the pandemic. Interview summaries were abstracted from recordings, and deductive codes were created for the primary question stems. These codes were subsequently reviewed for the main themes. Results: The main themes were as follows: adolescent social media and technology use during school closures usually allowed for more and easier social connectivity, but the amount and relative ease of connectivity differed according to purpose and type of use. Emotions, particularly those of stress and happiness, were connected to whether adolescents actively or passively engaged with social media and technology. Conclusions: Our results suggest a nuanced relationship among social media and technology use, adolescent social support, and emotional well-being, including during the pandemic. Specifically, how adolescents use or engage with web-based platforms greatly influences their ability to connect with others and their feelings of stress and happiness. In the context of the COVID-19 pandemic and as technology in general remains at the core of the adolescent experience, future research should continue to examine how adolescents navigate and use web-based spaces in beneficial and harmful ways. This will inform education and interventions that foster healthy social media and technological habits. [ABSTRACT FROM AUTHOR]

Firearm injury is a major cause of death, disability, and other harms to community well-being across the U.S. Economics and public health offer two complementary perspectives to conceptualize gun violence and formulate strategies to mitigate related harms. Economics offers methods and procedures for tabulating costs of firearm injury and offers an explicit, albeit imperfect normative framework to evaluate proposed interventions. Economics' focus on incentives, trade-offs, and resources constraints provides useful mechanisms for understanding illegal firearm markets and firearm use that can inform crime reduction efforts. Public health methods and interventions help to measure patterns of illness and disease, identify risks and protective factors, and inform prevention efforts for the most vulnerable individuals and communities. Public health also focuses attention on social determinants and structural factors in designing and evaluating interventions to prevent, address, and mitigate the consequences of gun violence. [ABSTRACT FROM AUTHOR]

From firearm suicide and homicide to unintended harm, a public-health approach can establish the knowledge and know-how needed to reduce suffering. [ABSTRACT FROM AUTHOR]

Letter to the Editor [ABSTRACT FROM AUTHOR]

Background: Drug overdose and firearm injury are two of the United States (US) most unrelenting public health crises, both of which have been compounded by the COVID-19 pandemic. Programs and policies typically focus on each epidemic, alone, which may produce less efficient interventions if overlap does exist. The objective is to examine whether drug overdose correlates with and is associated with firearm injury at the census tract level while controlling for neighborhood characteristics. Methods: An ecological study of census tracts in Indianapolis, Indiana from 2018 to 2020. Population rates per 100,000 and census tracts with the highest overlap of overdose and firearm injury were identified based on spatial clusters. Bivariate association between census tract characteristic and drug overdose and firearm violence rate within spatial clusters. Zero-inflated negative binominal regression was used to estimate if the drug overdose activity is associated with higher future firearm injury. Results: In high overdose—high firearm injury census tracts, rates of firearm injury and drug overdose are two times higher compared to city wide rates. Indicators of structural disadvantage and structural racism are higher in high overdose—high firearm injury census tracts compared to city-wide averages. Drug overdoses are associated with higher rates of firearm injury in the following year (IRR: 1.004, 95% CI 1.001, 1.007, p < 0.05), adjusting for census tract characteristics and spatial dependence. Conclusions: Drug overdose and firearm injury co-spatially concentrate within census tracts. Moreover, drug overdoses are associated with future firearm injury. Interventions to reduce firearm injuries and drug overdoses should be a co-response in high drug overdose—high firearm injury communities. [ABSTRACT FROM AUTHOR]

An editorial is presented in which the authors discuss gun rights and gun control in the U.S., particularly in the context of the terms "firearm injury" as opposed to "gun violence, and the connotations and impressions that those terms mean to various segments of the public. It also discusses terms and phrases concerning the intersection of suicide and firearms.

Background: Cybervictimization among adolescents is associated with multiple negative mental health consequences. Although pediatricians often screen for cyberbullying, validated and acceptable programs to reduce the frequency and impact of adolescent cybervictimization are lacking. Objective: This study uses agile qualitative methods to refine and evaluate the acceptability of a mixed-modality intervention, initiated within the context of usual pediatric care, for adolescents with a history of cyberharassment and cyberbullying victimization. Methods: Three groups of adolescents were successively recruited from an urban primary care clinic to participate in three consecutive iterations (1, 2, and 3) of the program, which consisted of a brief in-clinic intervention followed by 8 weeks of daily, automated SMS text messaging. After 2 weeks of messaging, iteration 1 (I1) participants completed semistructured interviews regarding intervention experiences. Participant feedback was evaluated via framework matrix analysis to guide changes to the program for iteration 2 (I2). Feedback from 2-week interviews of I2 participants was similarly used to improve the program before initiating iteration 3 (I3). Participants in all 3 iterations completed the interviews after completing the program (8 weeks). Daily response rates assessed participant engagement, and satisfaction questionnaires assessed acceptability. Results: A total of 19 adolescents (aged 13-17 years) reporting past-year cybervictimization were enrolled: 7 in I1, 4 in I2, and 8 in I3. Demographic variables included the following: a mean age of 15 (SD 1.5) years; 58% (11/19) female, 42% (8/19) male, 63% (12/19) Hispanic, 37% (7/19) non-Hispanic, 79% (15/19) people of color, and 21% (4/19) White. A total of 73% (14/19) self-identified as having a low socioeconomic status, and 37% (7/19) self-identified as lesbian, gay, or bisexual. The average past 12-month cybervictimization score at baseline was 8.2 (SD 6.58; range 2-26). Participant feedback was used to iteratively refine intervention content and design. For example, participants in I1 recommended that the scope of the intervention be expanded to include web-based conflicts and drama, rather than narrowly focusing on cyberbullying prevention. On the basis of this feedback, the I2 content was shifted toward more general de-escalation skills and bystander empowerment. Overall, 88.34% (940/1064) of the daily queries sent to participants across all 3 iterations received a reply. Participant satisfaction improved considerably with each iteration; 0% (0/7) of I1 participants rated the overall quality of Intervention to Prevent Adolescent Cybervictimization with Text message as excellent, compared to 50% (2/4) of I2 participants and 86% (6/7) of I3 participants. Engagement also improved between the first and third iterations, with participants replying to 59.9% (235/392) of messages in I1, compared to 79.9% (358/488) of messages in I3. Conclusions: This study shows the value of structured participant feedback gathered in an agile intervention refinement methodology for the development of a technology-based intervention targeting adolescents. [ABSTRACT FROM AUTHOR]

Introduction: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention.The aim of this study was to describe EPs’ beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED). Methods: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons’ Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate. Results: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home. Conclusions: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed. [ABSTRACT FROM AUTHOR]

The Hospital Surge Preparedness and Response Index is an all-hazards template developed by a group of emergency management and disaster medicine experts from the United States. The objective of the Hospital Surge Preparedness and Response Index is to improve planning by linking action items to institutional triggers across the surge capacity continuum. This responder tool is a non-exhaustive, high-level template: administrators should tailor these elements to their individual institutional protocols and constraints for optimal efficiency. The Hospital Surge Preparedness and Response Index can be used to provide administrators with a snapshot of their facility's current service capacity in order to promote efficiency and situational awareness both internally and among regional partners. [ABSTRACT FROM AUTHOR]

Introduction: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention.The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED). Methods: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate. Results: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home. Conclusions: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed. [ABSTRACT FROM AUTHOR]

I Background: i Approximately one third of older adults (aged >=65 years) in the United States own a gun ([1]); some of them will develop dementia or other impairments that limit their capacity to handle firearms safely ([2], [3]). The survey sample comprised adults living in a home with firearms, regardless of whether they were gun owners themselves; however, we restricted our analysis to older adults who owned firearms. Future questions include the utility of an "advance firearm agreement" ([2]) and the concept of "firearm retirement planning" as part of firearm ownership, as well as how this process parallels discussions about "driving retirement.". [Extracted from the article]

GetUsPPE.org has built a centralized platform to facilitate matches for PPE donations, with an active role in matching donors with the appropriate recipients. A manual match process was limited by volunteer hours, thus we developed an open-access matching algorithm using a linear programming-based transportation model. From April 14, 2020 to April 27, 2020, the algorithm was used to match 83,136 items of PPE to 135 healthcare facilities in need across the United States with a median of 214.3 miles traveled, 100% of available donations matched, met the full quantity of requested PPE for 67% of recipients matched, and with 46% matches under 30 miles traveled. Compared with the period April 1, 2020 to April 13, 2020, when PPE matching was manual, the algorithm resulted in a 280% increase in matches/day. This publicly available automated algorithm could be deployed in future situations when the healthcare supply chain is insufficient. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the extent to which the Theory of Planned Behavior (TPB) accounts for variability in intention to perform cardiopulmonary resuscitation (CPR) and to explore which constructs in the TPB most strongly predict intention to perform CPR among college students. Participants: Undergraduate college students (N = 588, 51% women) recruited between September and November 2016. Methods: A cross-sectional survey design. Results: Attitude was the strongest predictor of intention to perform CPR (β = 0.381, p <.001), followed by subjective norm (β = 0.303, p <.001), and perceived behavioral control (β = 0.167, p <.001). The TPB accounted for 51% of the variance in intention to perform CPR (F[3, 536] = 186, p <.001). Conclusion: Attitude and subjective norm are the strongest predictors of intention to perform CPR among college students. Resuscitation trainings that highlight positive outcomes and social norms associated with performing CPR may help bystanders form intentions to perform CPR in an emergency. [ABSTRACT FROM AUTHOR]

Background: The incidence of firearm injury and death in the United States is increasing. Although the health care-related effect of firearm injury is estimated to be high, existing data are largely cross-sectional, do not include data on preinjury and postinjury health care visits and related costs, and use hospital charges rather than actual monetary payments.Objective: To compare actual health care costs (that is, actual monetary payments) and utilizations within the 6 months before and after an incident (index) firearm injury.Design: Before-after study.Setting: Blue Cross Blue Shield plans of Illinois, Texas, Oklahoma, New Mexico, and Montana.Participants: Plan members continuously enrolled for at least 12 months before and after an index firearm injury sustained between 1 January 2015 and 31 December 2017.Measurements: Eligible costs, out-of-pocket costs, and firearm injury-related International Classification of Diseases, Ninth or 10th Revision, codes.Results: Total initial (emergency department [ED]) health care costs for persons with index firearm injuries who were discharged from the ED were $8 158 786 ($5686 per member). Total initial (hospital admission) costs for persons with index firearm injuries who required hospitalization were $41 255 916 ($70 644 per member). Compared with the 6 months before the index firearm injury, in the 6 months after, per-member costs increased by 347% (from $3984 to $17 806 per member) for those discharged from the ED and 2138% (from $4118 to $92 151 per member) for those who were hospitalized. The number of claims increased by 187% for patients discharged from the ED and 608% for those who were hospitalized.Limitation: Firearm injury intent was not specified because of misclassification concerns.Conclusion: In the 6 months after a firearm injury, patient-level health care visits and costs increased by 3 to 20 times compared with the 6 months prior. The burden of firearm injury on the health care system is large and quantifiable.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Firearm injury in the United States is a public health crisis in which physicians are uniquely situated to intervene. However, their ability to mitigate harm is limited by a complex array of laws and regulations that shape their role in firearm injury prevention. This piece uses four clinical scenarios to illustrate how these laws and regulations impact physician practice, including patient counseling, injury reporting, and the use of court orders and involuntary holds. Unintended consequences on clinical practice of laws intended to reduce firearm injury are also discussed. Lessons drawn from these cases suggest that physicians require more nuanced education on this topic, and that policymakers should consult front-line healthcare providers when designing firearm policies. [ABSTRACT FROM AUTHOR]

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: "I wonder if I'm broken"; (2) the importance of and need for mass casualty shooting preparedness: "[We need to] recognize this as a public health concern and train physicians to manage it"; (3) massive media attention: "The media onslaught was unbelievable"; and (4) commitment to advocacy for a public health approach to firearm violence: "I want to do whatever I can to prevent some of these terrible events." [ABSTRACT FROM AUTHOR]

Objective: This study examined emergency department (ED) and behavioral health (BH) provider attitudes and behaviors related to lethal means screening and counseling of patients with suicide risk, specifically examining differences by provider type and whether providers had firearms in their own home.Methods: Emergency department providers (physicians and mid-level practitioners) and behavioral health (BH) providers at four Colorado EDs completed an anonymous, web-based survey.Results: Fewer ED providers (35%) than BH providers (81%) felt confident in their ability to counsel patients about lethal means (p < .001). In multivariable analysis, the only clinical or provider factor associated with often or almost always asking patients about firearm access was provider type, with BH providers more likely than ED providers to ask in all scenarios (OR: 5.58, 95% CI 1.68-18.6). Behaviors and attitudes about lethal means counseling did not vary by whether the provider had firearms at home. Almost all providers said that additional training and protocols about how to help patients make firearm storage decisions would be helpful.Conclusions: Gaps in ED-delivered lethal means counseling persist, highlighting directions for future provider education and protocol development. [ABSTRACT FROM AUTHOR]

The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine the feasibility, acceptability and preliminary effects of an intervention, Skills to Enhance Positivity (STEP) that aims to increase attention to positive emotions and experiences and to decrease suicidal events. STEP involves four in-person individual sessions delivered during an inpatient psychiatric admission, followed by one month of weekly phone calls and daily text messages with mood monitoring and skills practice. A pilot randomized controlled trial of STEP vs. enhanced treatment as usual (ETAU) was conducted with 52 adolescents. Results indicated that on average 83% of the sessions were completed and that on 70% of the days, participants engaged with the text-messaging component of the intervention. Acceptability for both in-person and text-messaging components was also high, with satisfaction ratings averaging between good and excellent. STEP participants reported fewer suicide events than ETAU participants (6 vs. 13) after six months of follow-up. [ABSTRACT FROM AUTHOR]

Background: Buprenorphine-naloxone is an evidence-based treatment for Opioid Use Disorder. However, despite its efficacy, nearly half of participants are unsuccessful in achieving stabilization (i.e., period of time following medication induction in which medication dose is adjusted to be effective in reducing cravings/withdrawal, minimize potential side effects, and eliminate illicit substance use). This paper presents the study design and protocol for a digital health intervention designed to promote engagement in and adherence to buprenorphine treatment, offered through an outpatient addiction treatment center, through motivational enhancement and distress tolerance skills training. Personalized feedback interventions represent a promising method to effectively motivate engagement in and adherence to buprenorphine treatment. These interventions are generally brief, individually tailored, and have the potential to be delivered via mobile platforms. Distress tolerance, a transdiagnostic vulnerability factor, has been implicated in the development and maintenance of substance use. Targeting distress tolerance may improve substance use treatment outcomes by promoting the ability to persist in goal-directed activity even when experiencing physical or emotional distress. Methods: The study aims are to: (1) develop and refine an interactive computer- and text message-delivered personalized feedback intervention that incorporates distress tolerance skills training for persons who have elected to initiate outpatient buprenorphine treatment (iCOPE); (2) examine the feasibility, acceptability, and preliminary efficacy of iCOPE for increasing abstinence, adherence, and retention in treatment compared to a treatment as usual comparison condition; and, (3) examine potential mechanisms that may underlie the efficacy of iCOPE in improving outcomes, including motivation, distress tolerance, self-regulation, and negative affect. Discussion: Results of this study will be used to determine whether to proceed with further testing through a large-scale trial. This work has the potential to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use. Trial Registration NCT03842384 [ABSTRACT FROM AUTHOR]