Search

Purpose This purpose of this article is to frame firearm violence as a health and public health problem, to illustrate the magnitude of the problem, to examine factors that increase the risk to be injured by a firearm, or conversely, that confer protection, and to identify relevant priority areas for nursing science. Organizing construct Firearm violence results in physical and psychological injuries and is a global health priority. Firearm violence is categorized as intentional (interpersonal and self-inflicted) and unintentional (interpersonal and self-inflicted) and accounts for an estimated 196,000 to 220,000 nonconflict deaths annually. Methods We reviewed the theoretical and scientific literature to analyze the magnitude and geographic distribution of firearm violence, the factors associated with firearm injury, the consequences of firearm violence, and areas where nursing science can make an impact on prevention, outcomes, and recovery. Findings Firearm violence is a significant public health problem that affects the health of individuals, families, and communities. The burdens and contributors to firearm violence vary worldwide, making it important to understand the local context of this global phenomenon. Relevant areas of inquiry span primary prevention focusing on individual and environmental risk factors; and focus on managing the physical and psychological consequences postinjury; and mitigating long-term consequences of firearm violence. Conclusions Reducing the global burden of firearm violence and improving the health and safety of individuals, families, and communities provide compelling reasons to integrate this area into nursing science. Clinical relevance The goals of nursing are to keep people healthy and safe and to help return those injured to their optimal levels of health and well-being. Understanding the factors that come together to injure people with a firearm in various physical, social, economic, and cultural environments positions nurses to both extend the dialogue beyond pro-gun versus anti-gun and to design and carry out rigorous studies to reduce firearm violence.

Strengths-based strategies to reduce youth violence in low-resource urban communities are urgently needed. Supportive adolescent-adult relationships may confer protection, but studies have been limited by self-reported composite outcomes. We conducted a population-based case-control study among 10- to 24-year-old males in low-resource neighborhoods to examine associations between supportive adult connection and severe assault injury. Cases were victims of gunshot assault injury (n = 143) and non-gun assault injury (n = 206) from two level I trauma centers. Age- and race-matched controls (n = 283) were recruited using random digit dial from the same catchment. Adolescent-adult connections were defined by: (1) brief survey questions and (2) detailed family genograms. Analysis used conditional logistic regression. There were no significant associations between positive adult connection, as defined by brief survey questions, and either gunshot or non-gun assault injury among adolescents with high prior violence involvement (GSW OR = 2.46, 95% CI 0.81–7.49; non-gun OR = 1.59, 95% CI 0.54–4.67) or low prior violence involvement (GSW OR = 0.92, 95% CI 0.34–2.44; non-gun OR = 1.96, 95% CI 0.73–5.28). In contrast, among adolescents with high levels of prior violence involvement, reporting at least one supportive adult family member in the family genogram was associated with higher odds of gunshot assault injury (OR = 4.01, 95% CI 1.36–11.80) and non-gun assault injury (OR = 4.22, 95% CI 1.48–12.04). We were thus unable to demonstrate that positive adult connections protected adolescent males from severe assault injury in this highly under-resourced environment. However, at the time of injury, assault-injured adolescents, particularly those with high prior violence involvement, reported high levels of family support. The post-injury period may provide opportunities to intervene to enhance and leverage family connections to explore how to better safeguard adolescents. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11524-018-0260-8) contains supplementary material, which is available to authorized users.

We developed measures of benefits and burdens of research participation in cancer clinical trials using a sequential mixed methods design with a qualitative ( n = 32) and quantitative sample ( n = 110) of cancer clinical trial participants. Benefit–burden items (22 for benefits, 23 for burdens) were subsequently developed and assessed through cognitive interviewing for content, clarity, and meaning. Preliminary psychometric analyses support the internal consistency reliability and construct validity of Benefit (α = .90) and Burden (α = .87) research participation scales. Item response theory models supported the discrimination ability of the items on the scales. Participants who had thoughts of dropping out had lower Benefit scale scores ( p < .001) and higher Burden scores ( p < .001) than those who had no thoughts of dropping out, supporting construct validity. With further psychometric testing, the scale can be used to develop appropriate interventions to address recruitment and retention of human participants in clinical research.

OBJECTIVES: Psychological distress is common in survivors of traumatic injury, yet across United States’ trauma systems, it is rare that standard injury care integrates psychological evaluation and professional mental healthcare. The purpose of this study was to explore help-seeking for psychological symptoms in injured Black men living in Philadelphia. DESIGN: A subset of a cohort of 551 injured Black men admitted to a Trauma Center in Philadelphia participated in qualitative interviews that explored their perceptions of psychological symptoms after injury and the factors that guided their decision to seek professional mental health help. Data from 32 participants were analyzed for narrative and thematic content. RESULTS: Three overarching themes emerged: (1) facilitators of help-seeking, (2) barriers to help-seeking, and (3) factors underlying the decision not to consider professional help. Five participants felt that their injury-related psychological distress was severe enough to merit professional help despite any perceived barriers. Seventeen participants identified systemic and interpersonal obstacles to professional help that prevented them from seeking this kind of care. These included: financial constraints, limited access to mental healthcare services, and fear of the judgments of mental healthcare professionals. Ten participants would not consider professional help; these men perceived a lack of need and sufficiency in their existing social support networks. CONCLUSIONS: Research is needed to inform or identify interventions that diminish the impact of barriers to care, and identify from whom, where, and how professional mental health help might be more effectively offered to injured Black men in recovery environments like Philadelphia.

BACKGROUND/SIGNIFICANCE: Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. METHODS: This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting use of TIC in practice. RESULTS: Of 147 participants, the majority were nurses (65%), followed by therapists (18%), and physicians (17%), with a median 3 years of experience. 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. 19% rated themselves as less than “somewhat competent”. All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about re-traumatizing patients. Self-rated competence was the most consistent predictor of providers’ reported use of specific TIC practices. CONCLUSIONS: Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed, and should aim to build providers’ perceived competence in providing TIC.

Background Understanding the complex interrelationships between combat injuries, physical health, and mental health symptoms is critical to addressing the healthcare needs of wounded military personnel and veterans. The relationship between injury characteristics, pain, posttraumatic stress disorder (PTSD), and depression among combat-injured military personnel is unique to modern conflicts and understudied in the nursing literature. Aim This integrative review synthesizes clinical presentations and relationships of combat injury, PTSD, depression, and pain in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) United States military service members and veterans. Methods A literature search was conducted using relative key terms across databases to identify peer-reviewed publications between 2001 and 2016 that examined health outcomes of combat-injured persons in OEF and OIF. The quality of evidence was evaluated and results synthesized to examine the association of combat injury as a risk factor for PTSD, the relationship of PTSD and depression pre- and postinjury, and pain management throughout care. Results Twenty-two articles were included in this review. Greater injury and pain severity poses risks for developing PTSD following combat injury, while early symptom management lessens risks for PTSD. Depression appears to be both a contributing risk factor to postinjury PTSD, as well as a comorbidity. Linking evidence to action Findings demonstrate a compelling need for improvements in standardized assessment of pain and mental health symptoms across transitions in care. This integrative review informs nurse researchers and providers of the clinical characteristics of pain, PTSD, and depression following combat injury and offers implications for future research promoting optimal surveillance of symptoms.

Objectives. We analyzed a probability sample of Guatemalans to determine if a relationship exists between previous violent events and development of mental health outcomes in various sociodemographic groups, as well as during and after the Guatemalan Civil War. Methods. We used regression modeling, an interaction test, and complex survey design adjustments to estimate prevalences and test potential relationships between previous violent events and mental health. Results. Many (20.6%) participants experienced at least 1 previous serious violent event. Witnessing someone severely injured or killed was the most common event. Depression was experienced by 4.2% of participants, with 6.5% experiencing anxiety, 6.4% an alcohol-related disorder, and 1.9% posttraumatic stress disorder (PTSD). Persons who experienced violence during the war had 4.3 times the adjusted odds of alcohol-related disorders (P Conclusions. Violence that began during the civil war and continues today has had a significant effect on the mental health of Guatemalans. However, mental health outcomes resulting from violent events decreased in the postwar period, suggesting a nation in recovery.

PURPOSE: The purpose of this study was to explore the reasons adult patients seeking emergency department care for minor injuries agree to participate in clinical research and to identify their reservations about participating in a research study. DESIGN AND METHODS: This is a secondary analysis of data from a longitudinal cohort study of 275 adults who sought emergency department care for physical injury and were followed over 12 months. At the final interview, participants were asked open-ended short-answer questions about their perception of participating in the study. Free text responses were analyzed using conventional content analysis. FINDINGS: The final sample of 214 participants was composed equally of males and females, predominantly Black (54%) and White (42%), with a mean age of 41 years. Six themes about reasons for participation emerged from free text responses: being asked, altruism, potential for personal benefit, financial gain, curiosity, and valuing or knowledge of research. Most did not report reservations. Those reservations identified included time constraints, confidentiality, and whether patients felt well suited to fulfill the study requirements. CONCLUSIONS: Although injured patients are identified by the research community as vulnerable, they are willing to participate in research studies for diverse reasons, and their participation is commonly associated with positive experiences. CLINICAL RELEVANCE: Understanding perceptions of participants' experiences of being in a research study after acute injury can guide researchers to improve future study protocols and recruitment strategies in order to optimize participants' experiences. Recruitment and retention into clinical research studies is essential to build nursing science to enhance the recovery of injured individuals. Language: en

Importance Patient satisfaction is an increasingly common feature of quality measurement, and patient-centered care is a key aspect of high-quality clinical care. Incorporating patient preferences in an acute context, such as trauma resuscitation, presents distinct challenges; however, to our knowledge, patients’ experiences of trauma resuscitation have not been explored. Objectives To describe patient experiences of trauma resuscitation and to identify opportunities to improve patient experience without compromising speed or thoroughness. Design, Setting, and Participants This qualitative, descriptive study was conducted at an urban, academic, level I trauma center. Semistructured interviews and video observations were conducted from May to December 2015. Interview participants were adult English-speaking patients who had experienced trauma resuscitation and were clinically stable with no alteration in consciousness. We recruited interview participants and conducted video observations until thematic saturation was reached, resulting in 30 interviews and 20 observations. Video observation patients did not overlap with interview participants. The purposive sample included equal numbers of violently and nonviolently injured patients. Data were analyzed for thematic content from June 2015 to April 2016. Main Outcomes and Measures The main outcomes reported are themes of patient experience. Results Of 30 interview participants, 25 were men (83.3%), and 21 were black (70.0%). Of 20 video observation patients, 16 were men (80.0%), and 17 were black (85.0%). Salient aspects of patient experience of trauma resuscitation included emotional responses, physical experience, nonclinical concerns, treatment and procedures, trauma team members’ interactions, communication, and comfort. Participants drew satisfaction from trauma team members’ demeanor, expertise, and efficiency and valued clear clinical communication, as well as words of reassurance. Dissatisfaction stemmed from the perceived absence of these attributes and from participants’ emotional or physical discomfort. Observation data added insight into the components of care that may have contributed to participants’ responses and those aspects of care that were not salient to participants. Conclusions and Relevance Although the urgency of trauma care limits explicit discussion and consideration of patient priorities, we found that patient concerns corresponded well with trauma team goals. Patients perceived trauma team members as competent, efficient, and caring. Focusing on patient communication could further improve patient-centeredness in this setting.

Statement of purpose Green space and vegetation may play a protective role for urban violence. We investigated whether being near urban tree cover during outdoor activities related to being assaulted with a gun. Methods/approach We conducted GIS-assisted interviews with 10 to 24 year old males in Philadelphia, PA including 135 patients who had been shot with a firearm and 274 community controls. Each subject reported a step-by-step mapped account of where and with whom they travelled over a full day from waking until being assaulted or going to bed. Geocoded path points were overlaid on mapped layers representing tree locations and place-specific characteristics. Conditional logistic regressions compared case subjects versus controls (case-control) and case subjects at the time of injury versus times earlier that day (case-crossover). Results When comparing cases at the time of assault to controls matched at the same time of day, being under tree cover was inversely associated with gunshot assault (OR=0.70, 95% CI: 0.55, 0.88), especially in low-income areas (OR=0.69, 95%CI=0.54, 0.87). Case-crossover models confirmed this inverse association overall (OR=0.55, 95% CI=0.34, 0.89), and in low-income areas (OR=0.54, 95% CI=0.33, 0.88). Conclusion and Significance/contribution to Injury and Violence Prevention Science Urban greening and tree cover may hold promise as proactive strategies to decrease urban violence.

Purpose To describe the burden of post-injury PTSD and depression and the contribution of injury and acute stress responses to PTSD and depression severity 3 months post-discharge. Methods/Approach 607 seriously injured Black men were enrolled during hospitalisation for injury. 474 have completed follow-up 3 months post-discharge at the time of analysis. Demographics, injury characteristics (mechanism, injury severity), and acute stress responses: Trauma Screening Questionnaire (TSQ), Peri-traumatic Distress Inventory (PDI), Rand Peri-traumatic Dissociation Questionnaire (Rand), were collected in hospital. PTSD (PCL-5) and Depression (QIDSsr16) were collected 3 months post-discharge in the participant’s home, with higher scores reflecting more severe symptoms. Linear regression was used to identify characteristics associated with PTSD and depression symptom severity. Results Mean age 36.8 years (SD15.6). Mean Injury Severity 9.2 (SD7.5). 53% violent and 47% unintentional injury. 137 (28.8%) had PTSD and 169 (35.7%) had depression at 3 months. Significant correlates (p Conclusion Injury characteristics and acute psychological stress responses contribute to PTSD and depression at 3 months after discharge with the acute stress responses accounting for the largest part of variance. Understanding early for psychological responses to injury can help to guide comprehensive care for those at highest risk for post-injury PTSD and depression. Significance/Contribution Limited attention is paid to the psychological effects of the injury. For Black men who sustain serious injury, returning home from the hospital with unrecognised psychological consequences contributes to sub-optimal recovery. PTSD and depression may have behavioural manifestations that contribute to injury recidivism, self-medication for symptoms, or interactions with the criminal justice system.

Patients with traumatic injuries often interact with police before and during hospitalization, particularly when their injuries are due to violence. People of color are at highest risk for violent injuries and have the poorest outcomes after injury. The purpose of this study was to describe how injured, Black patients perceived their interactions with police and what these perceptions reveal about police involvement within trauma care systems. We combined data from two qualitative studies to achieve this aim. The first was ethnographic fieldwork that followed Black trauma patients in the hospital through the physical and emotional aftermath of their injuries. The second was a qualitative, descriptive study of how patients experienced trauma resuscitation in the emergency department (ED). Both studies were conducted between 2012 and 2015 at the Trauma Center at Penn, an academic medical center in Philadelphia, Pennsylvania, United States. The present study includes data from 24 adult, Black participants undergoing treatment for injury. We reanalyzed all interview data related to law enforcement encounters from the scene of injury through inpatient hospitalization and coded data using a constant comparative technique from grounded theory. Participants described law enforcement encounters at the scene of injury and during transport to the hospital, in the ED, and over the course of inpatient care. Injured participants valued police officers' involvement when they perceived that officers provided safety at the scene, speed of transport to the hospital, or support and information after injury. Injured participants also found police questioning to be stressful and, at times, disrespectful or conflicting with clinical care. Communities, trauma centers, and professional societies have the opportunity to enact policies that standardize law enforcement access in trauma centers and balance patients’ health, privacy, and legal rights with public safety needs.

Exposure to adverse neighbourhood conditions can negatively impact adolescent well-being and perceived safety. However, the impact of neighbourhood social trust on perceived safety is largely unknown. We studied 139 adolescent men to investigate how their perceptions of safety varied as a function of social trust levels in the neighbourhoods they traversed; neighbourhoods that were not necessarily their own. Adolescents mapped their minute-by-minute activities over a recent day and rated their perceived safety on a 10-point scale during in-person interviews. Neighbourhood social trust was measured via a citywide random sample survey. Mixed effects regression showed that, compared with their safety perceptions when in areas of low social trust, older adolescents were 73% more likely to feel unsafe when in areas of medium social trust, and 89% more likely to feel unsafe when in areas of high social trust. Inverse relationships between neighbourhood social trust and adolescents’ perceived safety highlight the complex interplay between youth, environmental contexts and safety.

Population health outcomes are directly related to robust public health programs, access to basic health services, and a well-trained health-care workforce. Effective health services need to systematically identify solutions, scientifically test these solutions, and share generated knowledge. The World Health Organization (WHO)'s Global Healthcare Workforce Alliance states that the capacity to perform research is an essential factor for well-functioning public health systems. Low- and middle-income countries have greater health-care worker shortages and lower research capacity than higher-income countries. International global health partnerships between higher-income countries and low-middle-income countries aim to directly address such inequalities through capacity building, a process by which human and institutional resources are strengthened and developed, allowing them to perform high-level functions, solve complex problems, and achieve important objectives. The Guatemala-Penn Partners (GPP) is a collaboration among academic centers in Guatemala and the University of Pennsylvania (Penn), in Philadelphia, Pennsylvania that echoes the vision of the WHO's Global Healthcare Workforce Alliance. This article describes the historical development and present organization of the GPP according to its three guiding principles: university-to-university connections, dual autonomies with locally led capacity building, and mutually beneficial exchanges. It describes the GPP activities within the domains of science, health-care education, and public health, emphasizing implementation factors, such as sustainability and scalability, in relation to the guiding principles. Successes and limitations of this innovative model are also analyzed in the hope that the lessons learned may be applied to similar partnerships across the globe.

Purpose Although previous research has made progress in identifying individuals predicted to face an elevated risk of being shot, it is not clear how that risk varies within individuals based on the contexts they encounter as they navigate daily life. The current study examines how the convergence of individual risk activity and neighborhood disadvantage and disorder triggers the risk of being shot. Methods Using a novel geographic information system application, 123 male gunshot assault victims between 10 and 24 years old in Philadelphia, Pennsylvania, described their minute-by-minute movements over the course of the day of the gunshot assault. Through latent class analysis, the primary exposure was real-life circumstance where nine theoretically informed risk factors converged, compared with two other circumstances. Case-crossover analyses of subjects' 10-minute segments of full-day activities compared gunshot assault victims at the time of assault with themselves earlier in the day. Results Compared to when individuals were exposed to minimal situational risk or were mainly exposed to neighborhood disadvantage and disorder, the concurrence of risk activity and neighborhood disadvantage and disorder was associated with a 9.90 (95% CI: 2.72–36.14) and 6.06 (95% CI: 2.78–13.22) times higher risk of being shot. Importantly, the likelihood of being in the high-risk circumstance increased systematically over the course of the day leading up to the time when young individuals were shot. Conclusions After controlled individual's propensity to be shot (e.g., inherent traits), the concurrence of situational risks emerged as significant triggers of gunshot assault. The findings suggest potential for community-based gunshot violence interventions.

Background Nursing science is essential to advance population health through contributions at all phases of scientific inquiry. Multiple scientific initiatives important to nursing science overlap in aims and population focus. Purpose This article focused on providing the American Academy of Nursing and nurse scientists in the Unites States with a blueprint of nursing science priorities to inform a shared vision for future collaborations, areas of scientific inquiry, and resource allocation. Methods The Science Committee convened four times and using Delphi methods identified priorities with empirical evidence and expert opinion for prioritization, state of the science, expert interest, and potential target stakeholders. Discussion Nursing science priorities for 2017 were categorized into four themes including: (a) precision science, (b) big data and data analytics, (c) determinants of health, and (d) global health. Conclusion Nurse scientists can generate new knowledge in priority areas that advances the health of the world's populations.

Of the studies that have been dedicated to understanding how often violence and fear of violence occur in transportation environments, characteristics of the offenders and the victims, and the nature and circumstances of the events, few studies have specifically focused on experiences of youth. Further, these studies have explored fear of violence by asking youth subjects global questions about their past experiences, rather than questions directly focused on the locations and times when youth were using a given mode of transportation. Such global approaches can produce data that do not accurately represent the topic of interest and are subject to considerable recall bias. Our motivation was to improve our understanding of fear of violence among youth. Doing so may help identify opportunities for preventing the circumstances that lead youth to feel unsafe and circumstances that put youth at risk of being the victims of violence.

To examine the impact of face-to-face restorative justice conference (RJC) meetings led by police officers between crime victims and their offenders on victims’ post-traumatic stress symptoms. Two trials conducted in London randomly assigned burglary or robbery cases with consenting victims and offenders to either a face-to-face restorative justice conference (RJC) in addition to conventional justice treatment or conventional treatment without a RJC. Post-traumatic stress symptoms (PTSS) were measured with the Impact of Event Scale-Revised (IES-R) within 1 month of treatment for 192 victims. We assessed the prevalence and severity of PTSS scores following treatment, using independent sample t tests and chi square statistics. We further measured the magnitude of the differences between the groups, using effect size analyses. Analyses show that PTSS scores are significantly lower among victims assigned to RJC in addition to criminal justice processing through the courts than to customary criminal justice processing alone. There are overall 49 % fewer victims with clinical levels of PTSS, and possible PTSD (IES-R ≥ 25). Main treatment effects are significant (t = 2.069; p

Opportunities for research-focused doctoral education must be available to nurses early in their careers in order to ensure the further development of nursing science. Early entry into the research doctorate through an integrated BSN-PhD program is one innovative approach. This approach highlights the value of integrating post-licensure clinical training into the doctoral curriculum. To better prepare innovative nurse scientists early in their careers we developed a clinical nurse fellowship within an integrated BSN-PhD program in partnership with an affiliated health system. The aims of this clinical fellowship are to integrate post-licensure clinical experience with academic preparation, cultivate scholarly reflection on the connections between research and practice, educate nurse researchers to work effectively in interdisciplinary teams, and develop nurses' contributions to health care innovation. Major considerations for the development of similar clinical training opportunities include clarifying and articulating the major aims of the fellowship, enlisting the support of executive clinical leadership, and placing fellows on nursing units with experienced and advanced nursing teams and management that supports the fellowship's aims. We emphasize the fully integrated and collaborative activities, decision-making, and commitment required of both academic and health system partners to successfully implement similar clinical training opportunities.

Purpose To describe quality of life (QoL) in the year following minor injury and to test the hypothesis that individuals with depression in the postinjury year experience lower QoL than do individuals with no depression.

Violence is increasingly viewed as a public health issue that may be ameliorated by health-based interventions. The Healthy Brains and Behavior Study (HBBS) aims to identify environmental and biological risk factors for aggression in late childhood and to reduce aggression through psychological and nutritional treatments. Utilizing a cross-disciplinary collaborative research approach, the HBBS has both human and animal components. The human component has two stages consisting of risk assessment followed by treatment. The risk assessment is based on 451 community-residing children aged 11–12 years and their caregivers, during which genetic, brain imaging, neuroendocrine, psychophysiology, environment toxicology, neurocognitive, nutrition, psychological, social and demographic risk variables are collected. Children who met criteria (N = 219) for problematic aggressive behaviors were assigned to one of four treatment groups: cognitive-behavior therapy (CBT) alone, nutritional supplements alone, both CBT and nutrition, or treatment-as-usual. Treatment duration was 12 weeks and all children whether in treatment or not were followed-up at three, six, and 12 months. The animal component assessed the effects of dietary omega-3 fatty acids on the development of aggression. This study contributes knowledge on how biological factors interact with social factors in shaping proactive and reactive aggression and assesses the efficacy of treatment approaches to reduce childhood aggression. Copyright © 2013 John Wiley & Sons, Ltd.

Children's safety as they travel to school is a concern nationwide. We investigated how safe children felt from the risk of being assaulted during morning travel to school.Children between 10 and 18 years old were recruited in Philadelphia and interviewed with the aid of geographic information system (GIS) mapping software about a recent trip to school, situational characteristics, and how safe they felt as they travelled based on a 10-point item (1 = very unsafe, 10 = very safe). Ordinal regression was used to estimate the probability of perceiving different levels of safety based on transportation mode, companion type, and neighborhood characteristics.Among 65 randomly selected subjects, routes to school ranged from 7 to 177 minutes (median = 36) and .1-15.1 street miles (median = 1.9), and included between 1-5 transportation modes (median = 2). Among students interviewed, 58.5% felt less than very safe (i.e.,10) at some point while traveling to school and one-third (32.5%) of the total person time was spent feeling less than very safe. Nearly a quarter of students, or 24.6%, felt a reduction in safety immediately upon exiting their home. The probability of reporting a safety of8, for example, was .99 while in a car and .94 while on foot but was .86 and .87 when on a public bus or trolley. Probability was .98 while with an adult but was .72 while with another child and .71 when alone. Also, perceived safety was lower in areas of high crime and high density of off-premise alcohol outlets.Efforts that target situational risk factors are warranted to help children feel safe over their entire travel routes to school.

Recruitment of community-based youth into studies is challenging. We examined access issues, minority status, and personal costs of participation for a study of children with aggressive behaviors, designed to identify which ones are at risk for future violent behaviors, to identify protective factors, and to test interventions to reduce aggression. Of 1,038 contacts, 112 declined, 239 could not be re-contacted, and 124 were ineligible. Three hundred and fifty of 563 scheduled child-parent dyads completed intake assessment. Most were recruited through targeted mailings (33%) and community flyers (22%), 12% through regional news advertisement, 8% by Craigslist, and 5% through healthcare providers/clinics. Factors contributing to enrollment rates by zip code showed the percentage of Black residents per zip code and targeted mailings positively contributed (Beta = .200 & .419, respectively) and estimated transit travel time negatively contributed (Beta =.299) to enrollment rates (R2 = 0.562). Targeted mailings proved to be the most efficient strategy in successful recruitment.

Introduction\ud A focus on what is important to patients has been recognized as an essential pillar in care to ensure safe patient care that focuses on outcomes identified as important by patients. Despite this, asking trauma patients and their families what they consider should be the priorities of care and recovery has been neglected.\ud \ud Methods\ud Adult trauma patients admitted to two centers in Australia for ≥24 h for the treatment of physical injury, and family members of injured patients and clinicians caring for injured patients were invited to participate. Individual interviews were conducted with the patient and family members prior to hospital discharge, and again one and three months post discharge. Individual interviews or focus groups were conducted with clinicians at one point in time. Content analysis of all transcripts was undertaken to determine the indicators of successful recovery over time.\ud \ud Results\ud Participants in the three stakeholder groups were enrolled (patients − 33; family members—22; clinicians—40). Indicators of recovery focused on five main categories including returning to work, resuming family roles, achieving independence, recapturing normality and achieving comfort. Other categories that were less frequently identified included maintaining one’s household, restoring emotional stability, cosmetic considerations and appearance, realignment of life goals, psychological recovery and development of self. Indicators of recovery after physical injury were similar across the three stakeholder groups, although with greater detail identified by patients. In addition, indicators evolved over time with increasing recognition of the importance of the overall impact of the injury in general and on activities of daily living and an unfolding appreciation that life could not be taken for granted.\ud \ud Conclusions\ud Description of the indicators of recovery after traumatic injury that matter to patients, family members and clinicians enable an understanding of similarities and differences. Further testing in a broader cohort of participants is essential to identify patient reported outcome measures that might be used in trauma care and associated research.

Background Family-centered rounds involve purposeful interactions between patients' families and care providers to refocus the delivery of care on patients' needs. Objectives To examine perspectives of patients' family members and health care providers on family participation in rounds in the surgical intensive care unit (ICU) and the potential use of telemedicine to facilitate this process. Methods Patients' family members and surgical ICU care providers were recruited for semistructured interviews exploring stakeholders' perspectives on family participation in ICU rounds and the potential role of telemedicine. Thirty-two interviews were conducted, audio recorded, and transcribed verbatim. Common coding methods were facilitated by using NVivo 10. A mean coding agreement of 97.3% was calculated for 22% of transcripts. Results Both patients' family members and health care providers described inconsistent practices surrounding family participation in ICU rounds as well as barriers to and facilitators of family participation. Family members identified 3 primary logistical challenges to participation in ICU rounds: distance to hospitals, work/family obligations, and the rounding schedule. Both family members and providers reported receptivity to virtual participation as a potential solution to these challenges. Conclusions Understanding the barriers to and facilitators of family participation in ICU rounds is key to encouraging adoption of family-centered rounds. For families that live far away or have competing demands, telemedical options may facilitate participation.

The ACHIEVEability model of affordable housing aims to promote self-sufficiency by requiring enrollment in postsecondary education in exchange for subsidized housing. In this study, we exploit the quasi random assignment of ACHIEVEability participants (N = 84) to subsidized housing units to evaluate whether microneighborhood environments moderated participants' progress in postsecondary education. Participants progressed in their educational pursuits in line with program requirements, earning about 12 college credits per year. Neighborhood block group characteristics moderated this progress. Participants who were assigned to housing located in poorer, more violent, and less educated block groups earned credits at a significantly slower rate than participants assigned housing in more advantaged block groups. Our results suggest that the micro environments immediately surrounding residents of subsidized housing matter, even if they are situated within broader contexts of spatial and personal disadvantage.

Green space and vegetation may play a protective role against urban violence. We investigated whether being near urban tree cover during outdoor activities was related to being assaulted with a gun. We conducted geographic information systems-assisted interviews with boys and men aged 10-24 years in Philadelphia, Pennsylvania, including 135 patients who had been shot with a firearm and 274 community controls, during 2008-2011. Each subject reported a step-by-step mapped account of where and with whom they traveled over a full day from waking until being assaulted or going to bed. Geocoded path points were overlaid on mapped layers representing tree locations and place-specific characteristics. Conditional logistic regressions were used to compare case subjects versus controls (case-control) and case subjects at the time of injury versus times earlier that day (case-crossover). When comparing cases at the time of assault to controls matched at the same time of day, being under tree cover was inversely associated with gunshot assault (odds ratio (OR) = 0.70, 95% confidence interval (CI): 0.55, 0.88), especially in low-income areas (OR = 0.69, 95% CI: 0.54, 0.87). Case-crossover models confirmed this inverse association overall (OR = 0.55, 95% CI: 0.34, 0.89) and in low-income areas (OR = 0.54, 95% CI: 0.33, 0.88). Urban greening and tree cover may hold promise as proactive strategies to decrease urban violence.

IMPORTANCE: Homicide is a leading cause of adolescent mortality. To our knowledge, relatively little has been studied in terms of the association between environmental neighborhood features, such as streets, buildings, and natural surroundings, and severe violent injury among youth. OBJECTIVE: To assess associations between environmental neighborhood features and adolescent homicide in order to identify targets for future place-based interventions. DESIGN, SETTING, AND PARTICIPANTS: Population-based case-control study conducted in Philadelphia, Pennsylvania, from April 15, 2008, to March 31, 2014. We identified adolescents who died by homicide at 13 to 20 years of age from 2010 to 2012 while residing in Philadelphia. We used incidence-density sampling and random-digit dialing to recruit control participants ages 13 to 20 years matched on sex and indoor-outdoor location at the time of each index case participant's homicide. EXPOSURES: To obtain environmental data about modifiable features that were present in the immediate surroundings of our case and control participants, blinded field researchers used standardized techniques to photograph case and control participant outdoor locations. Photographic data were stitched together to create 360 EXPOSURES: ° panoramic images that were coded for 60 elements of the visible environment. MAIN OUTCOME AND MEASURE: Adolescent homicide. RESULTS: We enrolled 143 homicide case participants (mean [SD] age, 18.4 [1.5] years) and 155 matched control participants (mean [SD] age, 17.2 [2.1] years) who were both outdoors at the time of the homicide. In adjusted analyses, multiple features of Philadelphia streets, buildings, and natural surroundings were associated with adolescent homicide. The presence of street lighting (odds ratio [OR], 0.24; 95% CI, 0.09-0.70), illuminated walk/don't walk signs (OR, 0.16; 95% CI, 0.03-0.92), painted marked crosswalks (OR, 0.17; 95% CI, 0.04-0.63), public transportation (OR, 0.13; 95% CI, 0.03-0.49), parks (OR, 0.09; 95% CI, 0.01-0.88), and maintained vacant lots (OR, 0.17; 95% CI, 0.03-0.81) were significantly associated with decreased odds of homicide. The odds of homicide were significantly higher in locations with stop signs (OR, 4.34; 95% CI, 1.40-13.45), security bars/gratings on houses (OR, 9.23; 95% CI, 2.45-34.80), and private bushes/plantings (OR, 3.44; 95% CI, 1.18-10.01). CONCLUSIONS AND RELEVANCE: Using a population-based case-control design, we identified multiple modifiable environmental features that might be targeted in future randomized intervention trials designed to reduce youth violence by improving neighborhood context. Language: en

To assess if violent deaths were associated with pay days in Guatemala.Interrupted time series analysis.Guatemalan national autopsy databases.Daily violence-related autopsy data for 22 418 decedents from 2009 to 2012. Data were provided by the Guatemalan National Institute of Forensic Sciences. Multiple pay-day lags and other important days such as holidays were tested.Absolute and relative estimates of excess violent deaths on pay days and holidays.The occurrence of violent deaths was not associated with pay days. However, a significant association was observed for national holidays, and this association was more pronounced when national holidays and pay days occurred simultaneously. This effect was observed mainly in males, who constituted the vast majority of violent deaths in Guatemala. An estimated 112 (coefficient=3.12; 95% CI 2.15 to 4.08; p0.01) more male violent deaths occurred on holidays than were expected. An estimated 121 (coefficient=4.64; 95% CI 3.41 to 5.88; p0.01) more male violent deaths than expected occurred on holidays that coincided with the first 2 days following a pay day.Men in Guatemala experience violent deaths at an elevated rate when pay days coincide with national holidays. Efforts to be better prepared for violence during national holidays and to prevent violent deaths by rescheduling pay days when these days co-occur with national holidays should be considered.

BACKGROUND: While some studies suggest that nutritional supplementation may reduce aggressive behavior in children, they have not examined whether its efficacy may be enhanced in conjunction with other treatment approaches. This study tests the hypothesis that a nutritional supplementation of omega-3, multivitamins, and minerals over 3 months, combined with cognitive behavior therapy, will reduce childhood aggression. METHODS: In this randomized, single-blind, stratified, factorial trial, a high-risk community sample of 290 children aged 11-12 years were randomized into Nutrition only, cognitive behavioral therapy (CBT) only, Nutrition + CBT, and Control groups. The primary outcome measures of child- and parent-reported aggressive and antisocial behavior were collected at 0 months (baseline), 3 months (end of treatment), 6 months (3 months posttreatment), and 12 months (9 months posttreatment). The trial ('Healthy Brains & Behavior: Understanding and Treating Youth Aggression (HBB)' was registered at ClinicalTrials.gov at https://clinicaltrials.gov/ct2/show/NCT00842439 RESULTS: For child self-reports, children in the Nutrition only group showed reduced externalizing behavior compared to Controls at 3 months. At 6 months, the Nutrition + CBT group scored lower on externalizing behavior compared to both CBT only and Control groups. FINDINGS were more in evidence for an Aggressive-Reactive form of antisocial behavior than for a Callous-Proactive form. Effect sizes were in the small-to-medium range (d = -.33 to -.37). Group differences were not sustained 9 months posttreatment, and no other effects were significant. CONCLUSIONS: Findings provide some limited support for the efficacy of omega-3, vitamin, and mineral supplementation in reducing aggressive behavior in children, and represent the first evaluation of nutritional supplements in conjunction with CBT.© 2016 Association for Child and Adolescent Mental Health. Language: en

The health and well-being of single-parent families living in violent neighbourhoods in US cities who participate in housing programmes is not well described. This two-phase, mixed-methods study explores the health status of families who were participants in a housing-plus programme in Philadelphia, Pennsylvania between 2011 and 2013 and the relationship between the characteristics of the neighbourhoods in which they lived and their perceptions of well-being and safety. In phase 1, data collected with standardised health status instruments were analysed using descriptive statistics and independent sample t-tests to describe the health of single parents and one randomly selected child from each parent's household in comparison to population norms. In a subset of survey respondents, focus groups were conducted to generate an in-depth understanding of the daily lives and stressors of these families. Focus group data were analysed using content analysis to identify key descriptive themes. In phase 2, daily activity path mapping, surveys and interviews of parent-child dyads were collected to assess how these families perceive their health, neighbourhood and the influence of neighbourhood characteristics on the families' day-to-day experience. Narratives and activity maps were combined with crime data from the Philadelphia Police Department to analyse the relationship between crime and perceptions of fear and safety. Phase 1 data demonstrated that parent participants met or exceeded the national average for self-reported physical health but fell below the national average across all mental health domains. Over 40% reported moderate to severe symptoms of depression. Parents described high levels of stress resulting from competing priorities, financial instability, and concern for their children's well-being and safety. Analysis of phase 2 data demonstrated that neighbourhood characteristics exert influence over parents' perceptions of their environment and how they permit their children to move within it. This research suggests the need for robust research, programmatic and policy interventions to support housing-unstable families who live in neighbourhoods with high levels of violence.

This project explores the beliefs and perspectives of urban adults and youth regarding community violence prevention strategies and identifies points of overlap and differences of opinion that can contribute to the development of successful youth violence prevention programs. We coded transcript data from adults and 10–16-year-old youth from the same community. Research team members, including a community member research partner, created coding terms for theme development and summary statements. Adult and youth responses centered around three distinct themes: activities for youth, barriers to youth participation in activities, and ideal violence prevention strategies. When discussing community violence prevention strategies, adults and youth agreed on the importance of adult supervision, the need to improve safe transit to and egress from common sites of youth activities, and removing trash from the community. Healthcare and social service providers should take these methods and findings into consideration when counseling patients or clients.

Recruiting and retaining human participants in cancer clinical trials is challenging for many investigators. Although we expect participants to identify and weigh the benefits and burdens of research participation for themselves, it is not clear what burdens adult cancer participants perceive in relation to benefits. We identify key attributes and develop an initial conceptual framework of benefit and burden based on interviews with individuals enrolled in cancer clinical research.Semistructured interviews were conducted with a purposive sample of 32 patients enrolled in cancer clinical trials at a large northeastern cancer center. Krueger's guidelines for qualitative methodology were followed.Respondents reported a range of benefits and burdens associated with research participation. Benefits such as access to needed medications that subjects otherwise might not be able to afford, early detection and monitoring of the disease, potential for remission or cure, and the ability to take control of their lives through actively participating in the trial were identified. Burdens included the potentiality of side effects, worry and fear of the unknown, loss of job support, and financial concerns.Both benefit and burden influence research participation, including recruitment and retention in clinical trials. Dimensions of benefit and burden include physical, psychological, economic, familial, and social. Understanding the benefit-burden balance involved in the voluntary consent of human subjects is a fundamental tenet of research and important to ensure that subjects have made an informed decision regarding their decision to participate in clinical research.

Community-based participatory research (CBPR) has garnered increasing interest over the previous two decades as researchers have tackled increasingly complex health problems. In academia, professional presentations and articles are major ways that research is disseminated. However, dissemination of research findings to the people and communities who participated in the research is many times forgotten. In addition, little scholarly literature is focused on creative dissemination of research findings to the community using CBPR methods. We seek to fill this gap in the literature by providing an exemplar of research dissemination and partnership strategies that were used to complete this project. In this paper, we present a novel approach to the dissemination of research findings to our targeted communities through digital animation. We also provide the foundational thinking and specific steps that were taken to select this specific dissemination product development and distribution strategy.

A case-control study of 149 intentionally self-inflicted gun injury cases (including completed gun suicides) and 302 population-based controls was conducted from 2003 to 2006 in a major US city. Two focal independent variables, acute alcohol consumption and alcohol outlet availability, were measured. Conditional logistic regression was adjusted for confounding variables. Gun suicide risk to individuals in areas of high alcohol outlet availability was less than the gun suicide risk they incurred from acute alcohol consumption, especially to excess. This corroborates prior work but also uncovers new information about the relationships between acute alcohol consumption, alcohol outlets, and gun suicide. Study limitations and implications are discussed.

The purpose of this study was to investigate family functioning in the relationship between community violence exposure and 1) self-esteem and 2) confrontational coping in a sample of urban youth. Adhering to the tenets of community based participatory research, academic and community partners collaborated on a cross-sectional study with 110 community dwelling urban youth, ages 10–16 living in a city located in the Northeastern United States. As part of a larger survey, this analysis included selected items on lifetime community violence exposure, family functioning, self-esteem and use of confrontational coping strategies in response to community violence. Over 90% of the youth reported some type of lifetime community violence exposure. Controlling for age and gender, older youth and those with healthier family functioning had higher self-esteem; community violence exposure was not associated with self-esteem. Healthier family functioning was associated with decreased use of confrontational coping, though increasing amounts of community violence exposure was still associated with increased confrontational coping. Family can be protective in violent environments. Results from this study directly informed an intervention aimed at youth violence prevention. This study highlights how psychiatric and mental health nurses may be able to address the complex interplay of factors for youth living in violent environments.

Aims: This paper presents a model to advance nursing science and practice in trauma care. Background: The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum. Data Sources: Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990 – 2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken. Discussion: Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long term outcomes. Implications for Policy and Practice: This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice. Conclusion: Planning and integrating care across the trauma continuum, as well as recognition of the role of the injured person’s background, family and resources, will lead to improved long term outcomes.

Studies of place and health often classify a subject's exposure status according to that which is present in their neighborhood of residence. One's neighborhood is often proxied by designating it to be an administratively defined unit such as census tract, to make analysis feasible. Although it is understood that residential space and actual lived space may not correspond and therefore exposure misclassification may result, few studies have the opportunity to investigate the implications of this issue concretely. A population-based case-control study that is currently underway provides one such opportunity. Adolescent victims of assault in Philadelphia, Pennsylvania, USA, and a control sample of adolescents drawn randomly from the community are being enrolled to study how alcohol consumption and time spent nearby alcohol outlets - individual-level and environmental-level risk factors for violence, respectively - over the course of daily activities relate to the likelihood of being assaulted. Data from a rapport-building exercise consist of hand-drawn sketches that subjects drew on street maps when asked to indicate the area considered their neighborhood. The main data consist of self-reported, detailed paths of the routes adolescents traveled from one location to the next over the course of one full day. Having noticed interesting patterns as the data collection phase proceeds, we present here an analysis conducted with the data of 55 control subjects between 15 and 19 years old. We found that hand-drawn neighborhoods and activity paths did not correspond to census tract boundaries, and time subjects spent in close proximity to alcohol outlets during their daily activities was not correlated with the prevalence of alcohol outlets in the census tract of their residence. This served as a useful example demonstrating how classifying subjects as exposed based solely on the prevalence of the exposure in the geographic area of their residence may misrepresent the exposure that is etiologically meaningful.

Youth living in urban environments of pervasive violence are exposed to a variety of violence-related stressors. This qualitative descriptive study sought to ascertain how community-dwelling youth perceived exposure to violence and how these youth identified and used available resources. The intent of this community-based participatory research study was to help inform the design of a youth violence prevention center intervention. Semi-structured interviews were conducted with a purposive sample of 18 youth ages 10-16. Youth reported high levels of exposure to neighborhood violence. A theme of identifying and navigating safe and unsafe places emerged. Other stressors were more proximal and included interpersonal issues and conflicts. Youth used neighborhood and individual resources to cope with stressors. Youth maintained a high level of vigilance and developed clear strategies to safely navigate violent neighborhoods. Implications for youth due to the constant vigilance and exquisite sensitivity to stressors of chronic neighborhood violence are discussed. Language: en

We previously noted that older adults admitted to surgical ICUs (SICUs) are at high risk for delirium. In the current study, we describe the association between the presence of delirium and complications in older SICU patients, and describe the association between delirium occurring in the SICU and functional ability and discharge placement for older patients.Secondary analysis of prospective, observational, cohort study. Subjects were 114 consecutive patientsor= 65 years old admitted to a surgical critical care service. All subjects underwent daily delirium and sedation/agitation screening during hospitalization. Outcomes prospectively recorded included SICU complication development, discharge location, and functional ability (as measured by the Katz activities of daily living instrument).Nearly one third of older adults (31.6%) admitted to an SICU had a complication during ICU stay. There was a strong association between SICU delirium and complication occurrence (p = 0.001). Complication occurrence preceded delirium diagnosis for 16 of 20 subjects. Subjects with delirium in the SICU were more likely to be discharged to a place other than home (61.3% vs 20.5%, p0.0001) and have greater functional decline (67.7% vs 43.6%, p = 0.023) than nondelirious subjects. After adjusting for covariates including severity of illness and mechanical ventilation use, delirium was found to be strongly and independently associated with greater odds of being discharged to a place other than home (odds ratio, 7.20; 95% confidence interval, 1.93 to 26.82).Delirium in older surgical ICU patients is associated with complications and an increased likelihood of discharge to a place other than home.

Firearm violence is the end result of a causative web of individual-level and geographic risk factors. Few, if any, studies of firearm violence have been able to simultaneously determine the population-based relative risks that individuals experience as a result of what they were doing at a specific point in time and where they were, geographically, at a specific point in time. This paper describes the linkage of individual and geographic data that was undertaken as part of a population-based case-control study of firearm violence in Philadelphia. New methods and applications of these linked data relevant to researchers and policymakers interested in firearm violence are also discussed.

In the United States, firearms are involved in tens of thousands of deaths and injuries each year. The magnitude of this problem prompted the National Academy of Sciences (NAS) to issue a report in 2004 detailing the strengths and limitations of existing research on the relationship between firearms and violence. In response, a multidisciplinary group of experts in the field of firearms and violence formed the National Research Collaborative on Firearm Violence. The Collaborative met for 2 days in June 2005 to (1) critically review the main findings of the NAS report and (2) define a research agenda that could fill research and data gaps and inform policy that reduces gun-related crime, deaths and injuries. This article summarizes the Collaborative's conclusions and identifies priorities for research and funding.

Supplemental Digital Content is available in the text., Background: We collected detailed activity paths of urban youth to investigate the dynamic interplay between their lived experiences, time spent in different environments, and risk of violent assault. Methods: We mapped activity paths of 10- to 24-year-olds, including 143 assault patients shot with a firearm, 206 assault patients injured with other types of weapons, and 283 community controls, creating a step-by-step mapped record of how, when, where, and with whom they spent time over a full day from waking up until going to bed or being assaulted. Case–control analyses compared cases with time-matched controls to identify risk factors for assault. Case-crossover analyses compared cases at the time of assault with themselves earlier in the day to investigate whether exposure increases acted to the trigger assault. Results: Gunshot assault risks included being alone (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.3, 1.9) and were lower in areas with high neighbor connectedness (OR = 0.7, 95% CI = 0.6, 0.8). Acquiring a gun (OR = 1.4, 95% CI = 1.1, 1.6) and entering areas with more vacancy, violence, and vandalism (OR = 1.7, 95% CI = 1.1, 2.7) appeared to trigger the risk of getting shot shortly thereafter. Nongunshot assault risks included being in areas with recreation centers (OR = 1.2, 95% CI = 1.1, 1.4). Entering an area with higher truancy (OR = 1.6, 95% CI = 1.1, 2.5) and more vacancy, violence, and vandalism appeared to trigger the risk of nongunshot assault. Risks varied by age group. Conclusions: We achieved a large-scale study of the activities of many boys, adolescents, and young men that systematically documented their experiences and empirically quantified risks for violence. Working at a temporal and spatial scale that is relevant to the dynamics of this phenomenon gave novel insights into triggers for violent assault.

(p1⁄40.009), comprised more males (p1⁄40.05), died faster ( 48 hours vs. Interpretation: The mortality burden of trauma and sepsis in the TASH-ED is high, and mortality patterns differ between these groups. As emergency medicine develops as a specialty in Ethiopia, reduced mortality among these otherwise young, previously well patients could occur through targeted trauma prevention advocacy and the development of context-specific ED clinical care protocols. The generalizability of these study findings are limited by being a single-center study but hold great importance for informed improvements in ED care at Tikur Anbessa Hospital and likely approximate overall early ED mortality patterns in similarly-resourced ED settings in Ethiopia and other African countries. Funding: This project was funded by research grants from the University Health Network and the International Development Research Center. Abstract #: 02NCD007

Firearm injury is a disease that afflicts many individuals in the United States, either directly or indirectly. Trauma and critical care nurses have direct experience with this life-threatening disease and recognize the high lethality. The magnitude of this health problem requires a focus on primary prevention. We recognize that any focus on firearm injury is often contentious and political; however, nurses bring a ready-made credibility and focus on evidence-based practice to the prevention of this disease.

PURPOSE: To analyze the research published in peer-reviewed journals between 1996 and 2005 about factors affecting the physical outcomes of older adults after serious traumatic injury. ORGANIZING CONSTRUCT: Twenty-seven primary research studies published in the last 10 years pertained to in-hospital and long-term outcomes of serious injury among older adults. Research specific to isolated hip injury, traumatic brain injury, and burn trauma was excluded. METHODS: An integrative review of research published between January 1996 and January 2005 was carried out to examine the relationship between older age and outcome from severe injury. MEDLINE, BIOSIS previews, CINAHL, and PsycINFO databases were searched using the MeSH terms: injury, serious injury, trauma and multiple trauma, and crossed with type, severity, medical/surgical management, complication, outcome, mortality, morbidity, survival, disability, quality of life, functional status, functional recovery, function, and placement. FINDINGS: Older adults in these studies had higher short- and long-term mortality than did younger adults. The relationship between older age and poorer outcome persisted when adjusting for injury severity, number of injuries, comorbidities, and complications. At the same time, injury severity, number of injuries, complications, and gender each independently correlated with increased mortality among older adults. The body of research is limited by overreliance on retrospective data and heterogeneity in definitional criteria for the older adult population. CONCLUSIONS: Additional research is needed to clarify the contributory effect of variables such as psychosocial sequelae and physiologic resilience on injury outcome. The field of geriatric trauma would benefit from further population-based prospective investigation of the determinants of injury outcome in older adults in order to guide interventions and acute care treatment. Language: en

• Background For any given traumatic injury, older adults experience a longer hospitalization, more complications, and higher mortality than do younger patients. • Objectives To prospectively identify problems in designing follow-up studies in seriously injured older adults without head injury and to examine outcomes after serious trauma in older adults who were sent to a level I trauma center. • Methods A short-term descriptive follow-up design was used in which each patient served as his or her baseline. Eligible patients had injuries that required admission to an intensive care unit, a hospital length of stay longer than 72 hours, or surgery. Patients with isolated hip fractures, central nervous system injuries, and burn injuries were excluded. Data were collected by using standardized instruments during the acute hospital stay and 3 months after discharge from the hospital. • ResultsDuring a representative 2-month period, 21% of a potential 77 subjects died in the hospital, 44% had cognitive impairment that precluded participation, and 17% declined to participate. Twenty older adults (mean age 73.5 years) who were injured in motor vehicle crashes (45%), falls (35%), or pedestrian accidents (15%) or who had gunshot wounds (5%) were enrolled. Ten percent died after discharge. Levels of physical disability at 3 months after discharge were higher than those before the injury (score on Sickness Impact Profile physical subscale 24.5 vs 10.9, P = .02), and psychological distress (Impact of Event Scale score 20.9) remained elevated. • Conclusion Mortality, disability, and posttraumatic psychological distress after discharge are problems in seriously injured older adults.

Objective: Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality. Design: The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature. Main outcome measures: Non-conflict related firearm deaths. Results: Global non-conflict related firearm deaths were estimated to fall between 196 000 and 229 000, adjusted to the year 2000. 162 800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world's 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world's population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33 200 to 66 200. Conclusions: This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.