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The article offers a study which aims to deal with the lack of published data on trends of youth violent injury and the need for additional data on risk factors in Providence, Rhode Island. It evaluates the distribution of intentional and unintentional injury from weapons among youth in the city, the links and predictors of violent injuries, and accuracy of emergency departments (ED) coding of violent injury. The study shows that a standardized violent-injury registry may be the most accurate way in gathering accurate, comprehensive data on the characteristics of injured youth and injury circumstances.

The article informs about unconditional care in academic emergency departments with an attempt to provide the perspective of academic emergency departments (EDs) around the Nation. Topics include COVID-19 environment, uncertainties surrounding access to diagnostic testing, accuracy of this testing, available therapies, and mortality estimates, coupled with unprecedented social isolation policies; and epidemic has illuminated long-standing flaws and stress points in the U.S. healthcare system.

The author offers his comments about the reasons for and possible solutions to the low number of emergency medicine applications for individual mentored (K) awards. He references Dr. Jeremy Brown's article which articulated that few EM investigators apply for the K awards despite having a funding rate similar to other specialties. He points out that Dr. Brown's article was an important step for correcting misperceptions that EM investigators are less successful when they do apply.

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]

Nonfatal firearm assault incidents are more prevalent than gun homicides, however, little is understood about nonfatal firearm assault incidents due to a lack of accurate data in the United States. This is a descriptive study of all nonfatal firearm assault incidents identified through police and clinical records from 2007 to 2016 in Indianapolis, Indiana. Records were linked at the incident level to demonstrate the overlap and non-overlap of nonfatal firearm assault incidents in police and clinical records and describe differences in demographic characteristics of the victims. Incidents were matched within a 24-h time window of the recorded date of the police incident. Data were analyzed in fall 2020. There were 3797 nonfatal firearm assault incidents identified in police reports and 3131 clinical encounters with an ICD 9/10 diagnosis-based nonfatal firearm-related injury. 62% (n = 2366) of nonfatal firearm assault incidents matched within 24 h to a clinical encounter, 81% (n = 1905) had a firearm related ICD code: 40% (n = 947) were coded as a firearm-related assault, 32% (n = 754) were coded as a firearm-related accident; and 8.6% (n = 198) were coded as undetermined, self-inflicted or law enforcement firearm-related. The other 20% (n = 461) did not have an ICD firearm related diagnosis code. Results indicate most nonfatal firearm assault incidents overlap between police and clinical records systems, however, discrepancies between the systems exist. These findings also demonstrate an undercounting of nonfatal firearm assault incidents when relying on clinical data systems alone and more efforts are needed to link administrative police and clinical data in the study of nonfatal firearm assaults. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Most people with dementia (PWD) in the United States live in community settings supported by family and/or unpaid care partners. Firearms access is one of many decisions care partners navigate alongside PWD in efforts to prevent injuries and deaths. Conversations about firearms access are socially challenging, although specific challenges to be overcome have not been described.As part of the larger Safety in Dementia Trial, we interviewed care partners about their views and experiences regarding firearms access in the home where the PWD resides. Interviewees were English‐speaking adults (≥18 years) in the United States who are unpaid care partners of community‐dwelling PWD. Responses to interview discussions related to (1) a desire for safety, and (2) fear of firearm violence was analyzed using a focusing process to categorize views into essential themes.Fifty care partners, who were primarily female (58%), White (66%), adult children (56%), and living in the same household (64%), participated in interviews between February 2023–February 2024. Dominant themes emerging from the focusing technique included (1) firearms as a necessary component of home safety; (2) fear of accidental/impulsive firearm violence; (3) observed risk and “near misses”; and (4) differing views on home firearms as a source of conflict. Thematic descriptions did not differ according to care partner's relationship to the PWD (adult child, spouse, other).Considering whether and how to alter access to firearms where PWD reside can be difficult for care partners to navigate. Care partners expressed a desire to limit firearms access, but worried both about creating conflict with the PWD and the self‐defense implications of making firearms inaccessible. Findings were similar across subsets of care partners indicating that standardized tools and messaging to care partners may be effective in promoting safety in homes with PWD. [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: 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: 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]

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]

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]

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]

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]

The article presents the author's views on how to make effective policies on injury prevention. It is opined that one way is to educate lawmakers regarding the science of injury and violence prevention. According to the author, advocacy for the resources to support injury prevention research and implementation is also essential. It is stated that there is a need to build relationships between lawmakers and subject experts.

The article focuses on the task of emergency medicine physicians. According to the article, they specialize in the treatment of acutely ill and injured. However, they also functions as safety need for the most disadvantaged members of the society. It is stated that emergency physicians also find ways to deal with preventable injuries and other illnesses.

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]

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]

Digitization (using novel digital tools and strategies) and consumerism (taking a consumer-oriented approach) are increasingly commonplace in clinical trials, but the implications of these changes are not well described. We assembled a group of trial experts from academia, industry, non-profit, and government to discuss implications of this changing trial landscape and provide guidance. Digitization and consumerism can increase the volume and diversity of trial participants and expedite recruitment. However, downstream bottlenecks, challenges with retention, and serious issues with equity, ethics, and security can result. A "click and mortar" approach, combining approaches from novel and traditional trials with the thoughtful use of technology, may optimally balance opportunities and challenges facing many trials. We offer expert guidance and three "click and mortar" approaches to digital, consumer-oriented trials. More guidance and research are needed to navigate the associated opportunities and challenges. [ABSTRACT FROM AUTHOR]

• Examined self-harming behavior in sexual minority and heterosexual high-risk youth. • No group differences found in depression, clinical impairment, or life satisfaction. • Sexual minorities endorsed greater degree of non-suicidal self-injury. • Sexual minorities reported higher levels of suicide ideation but not behavior. • Abuse and victimization did not account for sexual minorities' greater self-harm. Within broader community samples, sexual minority adolescents (SMA, e.g., lesbian, gay, bisexual, queer) are at greater risk than their heterosexual counterparts for nonsuicidal self-injury (NSSI) and suicidal thoughts and behaviors. The present study investigated whether sexual minority orientation continues to confer additional risk for these behaviors in an already higher-risk sample of youth. Frequency and function of NSSI, suicidal behavior, and psychosocial factors were assessed in a sample of 52 adolescents (aged 12–18 years) admitted to an inpatient psychiatric unit due to suicide risk; 27 of them identified as SMA, and 25 as heterosexual (HA). Greater proportions of SMA reported engaging in lifetime NSSI, compared to HA, with a greater variety and frequency of NSSI behaviors and greater endorsement of intrapersonal NSSI functions. SMA reported higher levels of suicide ideation than HA, but not suicidal behavior. Group differences in NSSI and SI persisted when controlling for the greater prevalence of abuse and levels of peer-victimization reported by SMA. In inpatient clinical settings, SMA may be more likely than heterosexual youth to engage in NSSI, including more severe forms, and to experience suicide ideation. Providing alternative coping mechanisms may serve as treatment goals for reducing NSSI in SMA. [ABSTRACT FROM AUTHOR]

We appreciate Reierson's thoughtful commentary on our 2019 paper, which described our experiences, ethical process, judgment calls, and lessons from a 2016-2017 data-sharing pilot between Crisis Text Line and academic researchers. The commentary raises important questions about the ethical conduct of health research in the digital age, particularly regarding informed consent, potential conflicts of interest, and the protection of vulnerable populations. Our article focused specifically on the noncommercial use of Crisis Text Line data for research purposes, so we restrict our reply to points relevant to such usage. While we acknowledge the limitations of Crisis Text Line's Terms of Service as a means of informing users about data sharing for research, we maintain that our guidelines were ethically sound and aligned with well-established practices for institutional review board (IRB) review and researcher training. We emphasize the critical role of IRBs in ensuring that research involving vulnerable populations, including minors, is conducted ethically and with appropriate safeguards. Regarding potential conflicts of interest, we argue that unpaid, nonfiduciary advisory board service for a nonprofit organization does not constitute a conflict requiring disclosure. The transparent nature of our collaboration with Crisis Text Line, as evidenced by the authorship and acknowledgments in our paper, further underscores our commitment to ethical research practices. We recognize the complexity and evolving nature of the challenges surrounding data-sharing partnerships in digital health research. As the field progresses, we remain committed to ongoing, transparent engagement and to refining best practices in collaboration with colleagues, stakeholders, and the public. Our response aims to provide clarity and context for the concerns raised in the commentary while reaffirming the integrity and value of our original work. Ultimately, we maintain that our paper contributed meaningfully to the ongoing discourse on ethical data sharing and laid the groundwork for future improvements in this critical area of digital health research., (©Anthony R Pisani, Carlos Gallo, Madelyn S Gould, Nitya Kanuri, John E Marcotte, Brian Pascal, David Rousseau, Megan L Ranney, Bob Filbin, Shairi Turner. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.01.2025.)

The United States faces urgent public health challenges, including high preventable death rates, pervasive health disparities, and emerging health risks, despite unprecedented medical progress. This article, part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2025 initiative, presents a vision for modernizing the US public health system to address these twenty-first-century challenges through federally supported partnerships with health care, social services, and community organizations. We identify actions to address persistent public health challenges that stem from insufficient and fragmented funding models, inadequate data infrastructure, workforce vulnerabilities, and limited public trust. Our proposals focus on four areas: enabling cross-sector collaboration, aligning financing mechanisms with accountability for population health outcomes, improving data systems, and building a ready workforce. These changes would enable significant improvements in population health outcomes and reductions in health disparities and provide a stronger foundation for a "team-based" future public health enterprise.

Importance: Updated knowledge regarding the global prevalence of long COVID (or post-COVID-19 condition), its subtypes, risk factors, and variations across different follow-up durations and geographical regions is necessary for informed public health recommendations and healthcare delivery., Objective: The primary objective of this systematic review is to evaluate the global prevalence of long COVID and its subtypes and symptoms in individuals with confirmed COVID-19 diagnosis, while the secondary objective is to assess risk factors for long COVID in the same population., Data Sources: Studies on long COVID published from July 5, 2021, to May 29, 2024, searched from PubMed, Embase, and Web of Science were used for this systematic review. Supplemental updates to the original search period were made., Study Selection: There were four inclusion criteria: (1) human study population with confirmed COVID-19 diagnosis; (2) appropriate index diagnosis date; (3) outcome must include either prevalence, risk factors, duration, or symptoms of long COVID; and (4) follow-up time of at least two months after the index date. The exclusion criteria were: (1) non-human study population; (1) case studies or reviews; (2) studies with imaging, molecular, and/or cellular testing as primary results; (3) studies with specific populations such as healthcare workers, residents of nursing homes, and/or those living in long-term care facilities; and (4) studies that did not meet the sample size threshold needed to estimate overall prevalence with margin of error of 0.05., Data Extraction and Synthesis: Two screeners independently performed screenings and data extraction, and decision conflicts were collectively resolved. The data were pooled using a random-effects meta-analysis framework with a DerSimonian-Laird inverse variance weighted estimator., Main Outcomes and Measures: The primary estimand (target population parameter of interest) was the prevalence of long COVID and its subtypes among individuals with confirmed COVID-19 diagnoses, and the secondary estimand was effect sizes corresponding to ten common risk factors of long COVID in the same population., Results: A total of 442 studies were included in this mega-systematic review, and 429 were meta-analyzed for various endpoints, avoiding duplicate estimates from the same study. Of the 442 studies, 17.9% of the studies have a high risk of bias. Heterogeneity is evident among meta-analyzed studies, where the I 2 statistic is nearly 100% in studies that estimate overall prevalence. Global estimated pooled prevalence of long COVID was 36% among COVID-19 positive individuals (95% confidence interval [CI] 33%-40%) estimated from 144 studies. Geographical variation was observed in the estimated pooled prevalence of long COVID: Asia at 35% (95% CI 25%-46%), Europe at 39% (95% CI 31%-48%), North America at 30% (95% CI 24%-38%), and South America at 51% (95% CI 35%-66%). Stratifying by follow-up duration, the estimated pooled prevalence for individuals with longer follow-up periods of 1 to 2 years (47% [95% CI 37%-57%]) compared to those with follow-up times of less than 1 year (35% [95% CI 31%-39%]) had overlapping CI and were therefore not statistically distinguishable. Top five most prevalent long COVID subtypes among COVID-19 positive cases were respiratory at 20% (95% CI 14%-28%) estimated from 31 studies, general fatigue at 20% (95% CI 18%-23%) estimated from 121 studies, psychological at 18% (95% CI 11%-28%) estimated from 10 studies, neurological at 16% (95% CI 8%-30%) estimated from 23 studies, and dermatological at 12% (95% CI 8%-17%) estimated from 10 studies. The most common symptom based on estimated prevalence was memory problems estimated at 11% (95% CI 7%-19%) meta-analyzed from 12 studies. The three strongest risk factors for long COVID were being unvaccinated for COVID-19, pre-existing comorbidity, and female sex. Individuals with any of these risk factors had higher odds of having long COVID with pooled estimated odds ratios of 2.34 (95% CI 1.49-3.67) meta-analyzed from 6 studies, 1.59 (95% CI 1.28-1.97) from 13 studies, and 1.55 (95% CI 1.25-1.92) from 22 studies, respectively., Conclusions and Relevance: This study shows long COVID is globally prevalent in the COVID-19 positive population with highly varying estimates. The prevalence of long COVID persists over extended follow-up, with a high burden of symptoms 1 to 2 years post-infection. Our findings highlight long COVID and its subtypes as a continuing health challenge worldwide. The heterogeneity of the estimates across populations and geographical regions argues for the need for carefully designed follow-up with representative studies across the world., Competing Interests: Conflict of Interest Disclosures Authors have no competing interests.

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., (© Adam K Lewkowitz, Melissa Guillen, Katrina Ursino, Rackeem Baker, Liana Lum, Cynthia L Battle, Crystal Ware, Nina K Ayala, Melissa Clark, Megan L Ranney, Emily S Miller, Kate M Guthrie. Originally published in JMIR Human Factors (https://humanfactors.jmir.org).)

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., Competing Interests: Disclosures: Disclosure forms are available with the article online.

Background: Most people with dementia (PWD) in the United States live in community settings supported by family and/or unpaid care partners. Firearms access is one of many decisions care partners navigate alongside PWD in efforts to prevent injuries and deaths. Conversations about firearms access are socially challenging, although specific challenges to be overcome have not been described., Methods: As part of the larger Safety in Dementia Trial, we interviewed care partners about their views and experiences regarding firearms access in the home where the PWD resides. Interviewees were English-speaking adults (≥18 years) in the United States who are unpaid care partners of community-dwelling PWD. Responses to interview discussions related to (1) a desire for safety, and (2) fear of firearm violence was analyzed using a focusing process to categorize views into essential themes., Results: Fifty care partners, who were primarily female (58%), White (66%), adult children (56%), and living in the same household (64%), participated in interviews between February 2023-February 2024. Dominant themes emerging from the focusing technique included (1) firearms as a necessary component of home safety; (2) fear of accidental/impulsive firearm violence; (3) observed risk and "near misses"; and (4) differing views on home firearms as a source of conflict. Thematic descriptions did not differ according to care partner's relationship to the PWD (adult child, spouse, other)., Conclusions: Considering whether and how to alter access to firearms where PWD reside can be difficult for care partners to navigate. Care partners expressed a desire to limit firearms access, but worried both about creating conflict with the PWD and the self-defense implications of making firearms inaccessible. Findings were similar across subsets of care partners indicating that standardized tools and messaging to care partners may be effective in promoting safety in homes with PWD., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Postpartum depression (PPD) is more common among pregnant patients who have unmet social needs, such as financial stress or food insecurity, compared to those who do not. Mothers and Babies (MB) is a cognitive behavioral therapy (CBT)-based program that prevents up to 50% of de novo PPD when provided in-person to low-income Spanish- and English-speaking pregnant people without depression. MB's reach has been limited by the need for trained personnel to support the program. Transforming MB into a smartphone application (app) may mitigate this key barrier to scaling MB., Objective: To utilize 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 CBT-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 six months postpartum 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 Framework for Modification and Adaptation (FRAME), an established method of systematically reporting adaptations and modifications to evidence-based interventions via end-user feedback. Recruitment ceased with content saturation, defined as three successive participants providing only positive feedback on MBapp's wireframe, without further suggestions for improvement., Results: 25 interviews were completed. Participants were racially and ethnically diverse, generally representing our target end-user population, and 48% 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" non-urgent 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 (non)negotiables 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.

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., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M24-0430.

Objective: To determine if firearm ownership is positively related to elevated child lead levels at a state-level, even when accounting for other sources of lead., Study Design: For this cross-sectional ecological study, we investigated whether household firearm ownership rates (a proxy for firearm-related lead exposure) was associated with the prevalence of elevated child blood lead levels in 44 US States between 2012 and 2018. To account for potential confounding, we adjusted for other known lead exposures, poverty rate, population density, race, and calendar year. To address missing data, we used multiple imputation by chained equations., Results: Prevalence of elevated child blood lead positively correlated with household firearm ownership and established predictors of lead exposure. In fully adjusted negative binomial regression models, child blood lead was positively associated with household firearm ownership and older housing; each IQR (14%) increase in household firearm ownership rate was associated with a 41% higher prevalence of childhood elevated blood lead (prevalence ratio: 1.41, 95% CI: 1.11-1.79)., Conclusion: These data provide state-level evidence that firearms may be an important source of child lead exposure. More research is needed to substantiate this relationship and identify modifiable pathways of exposure at the individual level., Competing Interests: Declaration of Competing Interest JMB has been compensated for serving as an expert witness for plaintiffs involved in PFAS-contaminated drinking water and has NIH funding: R21 ES034187. MR has grants from the CDC and NIH related to firearm injury, and has unpaid roles as Senior Strategic Advisor to AFFIRM at the Aspen Institute and as a Board Member for the NonViolence Institute. The other authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Conflict-of-Interest Disclosures: Dave Chokshi, MD, reports serving as Chair of the Common Health Coalition. Melissa Harvey, MSPH, BSN, RN, reports personal fees from ChangeLab Solutions, outside this paper. Megan Ranney, MD, MPH, reports being a trustee of the National Opioid Abatement Trust-II, outside this paper. Carlos del Rio, MD, reports grants from NIH/NIAID (Emory CFAR), personal fees from Roche diagnostics, outside this paper. Mark B. McClellan, MD, PhD, reports personal fees from Johnson and Johnson Board of Directors, personal fees from Cigna Board of Directors, personal fees from Alignment Healthcare Board of Directors, personal fees from PrognomIQ, personal fees from Arsenal Capitol Partners, personal fees from Blackstone Life Sciences, personal fees from MITRE, other from Guiding Committee for the Health Care Payment Learning and Action Network, outside this paper.

Background: This systematic review summarizes the development, accuracy, quality, and clinical utility of predictive models to assess the risk of opioid use disorder (OUD), persistent opioid use, and opioid overdose., Methods: In accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines, 8 electronic databases were searched for studies on predictive models and OUD, overdose, or persistent use in adults until June 25, 2023. Study selection and data extraction were completed independently by 2 reviewers. Risk of bias of included studies was assessed independently by 2 reviewers using the Prediction model Risk of Bias ASsessment Tool (PROBAST)., Results: The literature search yielded 3130 reports; after removing 199 duplicates, excluding 2685 studies after abstract review, and excluding 204 studies after full-text review, the final sample consisted of 41 studies that developed more than 160 predictive models. Primary outcomes included opioid overdose (31.6% of studies), OUD (41.4%), and persistent opioid use (17%). The most common modeling approach was regression modeling, and the most common predictors included age, sex, mental health diagnosis history, and substance use disorder history. Most studies reported model performance via the c statistic, ranging from 0.507 to 0.959; gradient boosting tree models and neural network models performed well in the context of their own study. One study deployed a model in real time. Risk of bias was predominantly high; concerns regarding applicability were predominantly low., Conclusions: Models to predict opioid-related risks are developed using diverse data sources and predictors, with a wide and heterogenous range of accuracy metrics. There is a need for further research to improve their accuracy and implementation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 American Society of Addiction Medicine.)

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)