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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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Yen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Diagnosis is a core component of effective health care, but misdiagnosis is common and can put patients at risk. Diagnostic decision support systems can play a role in improving diagnosis by physicians and other health care workers. Symptom checkers (SCs) have been designed to improve diagnosis and triage (ie, which level of care to seek) by patients., Objective: The aim of this study was to evaluate the performance of the new large language model ChatGPT (versions 3.5 and 4.0), the widely used WebMD SC, and an SC developed by Ada Health in the diagnosis and triage of patients with urgent or emergent clinical problems compared with the final emergency department (ED) diagnoses and physician reviews., Methods: We used previously collected, deidentified, self-report data from 40 patients presenting to an ED for care who used the Ada SC to record their symptoms prior to seeing the ED physician. Deidentified data were entered into ChatGPT versions 3.5 and 4.0 and WebMD by a research assistant blinded to diagnoses and triage. Diagnoses from all 4 systems were compared with the previously abstracted final diagnoses in the ED as well as with diagnoses and triage recommendations from three independent board-certified ED physicians who had blindly reviewed the self-report clinical data from Ada. Diagnostic accuracy was calculated as the proportion of the diagnoses from ChatGPT, Ada SC, WebMD SC, and the independent physicians that matched at least one ED diagnosis (stratified as top 1 or top 3). Triage accuracy was calculated as the number of recommendations from ChatGPT, WebMD, or Ada that agreed with at least 2 of the independent physicians or were rated "unsafe" or "too cautious.", Results: Overall, 30 and 37 cases had sufficient data for diagnostic and triage analysis, respectively. The rate of top-1 diagnosis matches for Ada, ChatGPT 3.5, ChatGPT 4.0, and WebMD was 9 (30%), 12 (40%), 10 (33%), and 12 (40%), respectively, with a mean rate of 47% for the physicians. The rate of top-3 diagnostic matches for Ada, ChatGPT 3.5, ChatGPT 4.0, and WebMD was 19 (63%), 19 (63%), 15 (50%), and 17 (57%), respectively, with a mean rate of 69% for physicians. The distribution of triage results for Ada was 62% (n=23) agree, 14% unsafe (n=5), and 24% (n=9) too cautious; that for ChatGPT 3.5 was 59% (n=22) agree, 41% (n=15) unsafe, and 0% (n=0) too cautious; that for ChatGPT 4.0 was 76% (n=28) agree, 22% (n=8) unsafe, and 3% (n=1) too cautious; and that for WebMD was 70% (n=26) agree, 19% (n=7) unsafe, and 11% (n=4) too cautious. The unsafe triage rate for ChatGPT 3.5 (41%) was significantly higher (P=.009) than that of Ada (14%)., Conclusions: ChatGPT 3.5 had high diagnostic accuracy but a high unsafe triage rate. ChatGPT 4.0 had the poorest diagnostic accuracy, but a lower unsafe triage rate and the highest triage agreement with the physicians. The Ada and WebMD SCs performed better overall than ChatGPT. Unsupervised patient use of ChatGPT for diagnosis and triage is not recommended without improvements to triage accuracy and extensive clinical evaluation., (©Hamish Fraser, Daven Crossland, Ian Bacher, Megan Ranney, Tracy Madsen, Ross Hilliard. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 03.10.2023.)

Importance: Despite the prevalence of posttraumatic stress symptoms after firearm injury, little is known about how firearm injury survivors connect with mental health services., Objective: To determine facilitators and barriers to mental health care engagement among firearm injury survivors., Design, Setting, and Participants: A qualitative study of 1-on-1, semistructured interviews conducted within a community setting in Indianapolis, Indiana, between June 2021 and January 2022. Participants were recruited via community partners and snowball sampling. Participants who survived an intentional firearm injury, were shot within Indianapolis, were aged 13 years or older, and were English speaking were eligible. Participants were asked to discuss their lives after firearm injury, the emotional consequences of their injury, and their utilization patterns of mental health services. Data were analyzed from August 2022 to June 2023., Main Outcomes and Measures: Survivors' lived experience after firearm injury, sources of emotional support, mental health utilization, and their desired engagement with mental health care after firearm injury., Results: A total of 18 participants (17 were Black [94%], 16 were male [89%], and 14 were aged between 13 and 24 years [77%]) who survived a firearm injury were interviewed. Survivors described family members, friends, and informal networks as their main source of emotional support. Barriers to mental health care utilization were perceived as a lack of benefit to services, distrust in practitioners, and fear of stigma. Credible messengers served as facilitators to mental health care. Survivors also described the emotional impact their shooting had on their families, particularly mothers, partners, and children., Conclusions and Relevance: In this study of survivors of firearm injury, findings illustrated the consequences of stigma and fear when seeking mental health care, inadequate trusted resources, and the need for awareness of and access to mental health resources for family members and communities most impacted by firearm injury. Future studies should evaluate whether community capacity building, digital health delivery, and trauma-informed public health campaigns could overcome these barriers to mitigate the emotional trauma of firearm injuries to reduce health disparities and prevent future firearm violence.

Background: 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., Methods: 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., Results: 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., Conclusion: 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., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rachel L. Randell is supported by the National Institute of General Medical Sciences and the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Numbers T32GM086330 and T32HD104576. RLR's spouse has financial relationships with Biogen and Merck & Co, Inc. Lesley Curtis received contract support from Janssen and Vir Biotechnology and consulting fees from Regeneron. Adrian F. Hernandez received contract support from Pfizer Inc. and Merck and consulting fees from Merck. Tom Denwood is employed by Population Health Partners LLP. Camille Nebeker has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Jeremy Sugarman receives support from NIH grants. He receives consulting fees as part of an Ethics Advisory panel as well as travel reimbursement from Merck KGaA and IQVIA. Dr. Sugarman participates on a Data Safety Monitoring Board for Merck and a Clinical Advisory Panel for Aspen Neurosciences. He also has stock options in Aspen Neurosciences, Inc. Benoit Tyl is employed by Bayer. Masahiro Murakami is employed by and owns stock in Eli Lilly & Company. Leslie Oley Wilberforce is employed by Evidation. Sherry Pagoto receives research funds from WW International and consulting fees from Fitbit and WW International. Ola Vedin is employed by Boehringer Ingelheim AB. Tomas Andersson is employed by and owns stock in AstraZeneca. Olveen Carrasquillo received support from NIH grants and PCORI. Dr. Carrasquillo received consulting fees from Duke University Medical Center and the University of Florida. Dr. Carrasquillo also participates in the Data Safety Monitoring Board for the NIH COPE Study and is on the Board of Directors for the Health Council of South Florida and Miami-Dade Area Health Education Center. Scott H. Kollins is employed by Akili, Inc. and owns stock in Akili, Inc. Jill Pellegrino is employed by CVS Health. Megan L. Ranney received support from NIH grants and a grant from the University of Wisconsin SMAHRT grant. Dr. Ranney also is a member of the Data Safety Monitoring Board for Project COBALT at the University of Pennsylvania., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (© 2023 Wiley Periodicals LLC.)

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., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0069.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Objective: The objective of this qualitative study is to gauge physician sentiment about an emergency department (ED) clinical decision support (CDS) system implemented in multiple adult EDs within a university hospital system. This CDS system focuses on predicting patients' likelihood of ED recidivism and/or adverse opioid-related events., Methods: The study was conducted among adult emergency physicians working in three EDs of a single academic health system in Rhode Island. Qualitative, semistructured interviews were conducted with ED physicians. Interviews assessed physicians' prior experience with predictive analytics, thoughts on the alert's placement, design, and content, the alert's overall impact, and potential areas for improvement. Responses were aggregated and common themes identified., Results: Twenty-three interviews were conducted (11 preimplementation and 12 postimplementation). Themes were identified regarding each physician familiarity with predictive analytics, alert rollout, alert appearance and content, and on alert sentiments. Most physicians viewed these alerts as a neutral or positive EHR addition, with responses ranging from neutral to positive. The alert placement was noted to be largely intuitive and nonintrusive. The design of the alert was generally viewed positively. The alert's content was believed to be accurate, although the decision to respond to the alert's call-to-action was physician dependent. Those who tended to ignore the alert did so for a few reasons, including already knowing the information the alert contains, the alert offering information that is not relevant to this particular patient, and the alert not containing enough information to be useful., Conclusion: Ultimately, this alert appears to have a marginally positive effect on ED physician workflow. At its most beneficial, the alert reminded physicians to deeply consider the care provided to high-risk populations and to potentially adjust their care and referrals. At its least beneficial, the alert did not affect physician decision-making but was not intrusive to the point of negatively impacting workflow., Competing Interests: None declared., (Thieme. All rights reserved.)

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

Competing Interests: The authors of this article have read the journal’s policy and has the following competing interest: Dr. Ranney receives grant funding from NIH and CDC for related work. She serves as a volunteer board member for the Nonviolence Institute in Providence, RI and as a volunteer Senior Strategic Advisor for AFFIRM at the Aspen Institute. Dr. Mueller and Dr. Lovelady have declared that no competing interests exist.

Competing Interests: Similar to Phase 1, in order to minimize conflicts of interest, CMSS, WHO, and NAM took steps to ensure the independence and objectivity of the advisory committee and this paper, in that authors were required to disclose financial and non-financial conflicts of interest (Kington et al., 2021). This paper represents the opinions of the authors and does not reflect a consensus position of CMSS; NAM; the National Academies of Sciences, Engineering, and Medicine; WHO; or the authors' organizations. The advisory committee did not receive payment for their contributions to this paper.Conflict-of-Interest Disclosures: Megan L. Ranney discloses receiving financial compensation from the National Opioid Abatement Trust II. Vineet Arora discloses receiving honoraria from the Journal of Hospital Medicine and UpToDate and receiving royalties from McGraw Hill. Don Dizon discloses receiving financial compensation from AstraZeneca and Clovis and stock options from Midi. Efrén J. Flores discloses receiving honoraria from Medscape and financial compensation from Journal of the American College of Radiology. Anjali Jain discloses sole proprietorship of Anjali Jain Research & Consulting, LLC. Richard Mularski discloses receiving grants from Gilead Sciences, Merck, and Pfizer. Claude Pinnock discloses former employment at Meta/Facebook.

Background: The COVID-19 pandemic provided a unique opportunity to examine social media and technology use during a time in which technology served as adolescents' primary form of socialization. The literature is mixed regarding how increased screen time during this period affected adolescent mental health and well-being. The mechanisms by which screen time use affected adolescent psychosocial outcomes are also unknown., Objective: We aimed to deepen our understanding of how social media and technology use, social connectivity, and emotional well-being intersected during pandemic-related school closures., Methods: English-speaking adolescents aged 13 to 17 years were recruited on Instagram for a brief screening survey; 39 participants were purposefully selected to complete a semistructured interview regarding their social media and technology use during the pandemic. Interview summaries were abstracted from recordings, and deductive codes were created for the primary question stems. These codes were subsequently reviewed for the main themes., Results: The main themes were as follows: adolescent social media and technology use during school closures usually allowed for more and easier social connectivity, but the amount and relative ease of connectivity differed according to purpose and type of use. Emotions, particularly those of stress and happiness, were connected to whether adolescents actively or passively engaged with social media and technology., Conclusions: Our results suggest a nuanced relationship among social media and technology use, adolescent social support, and emotional well-being, including during the pandemic. Specifically, how adolescents use or engage with web-based platforms greatly influences their ability to connect with others and their feelings of stress and happiness. In the context of the COVID-19 pandemic and as technology in general remains at the core of the adolescent experience, future research should continue to examine how adolescents navigate and use web-based spaces in beneficial and harmful ways. This will inform education and interventions that foster healthy social media and technological habits., (©Elisa Liang, Emily R Kutok, Rochelle K Rosen, Taylor A Burke, Megan L Ranney. Originally published in JMIR Mental Health (https://mental.jmir.org), 23.02.2023.)

Objective: This open pilot study examines the feasibility, acceptability, and qualitative outcomes of an interactive web- and text message-delivered personalized feedback intervention aimed at cultivating motivation and tolerance of distress for adults initiating outpatient buprenorphine treatment., Methods: Patients ( n  = 10) initiating buprenorphine within the past 8 weeks first completed a web-based intervention focused on enhancing motivation and providing psychoeducation on distress tolerance skills. Participants then received 8 weeks of daily personalized text messages that provided reminders of salient motivational factors and recommended distress tolerance-oriented coping skills. Participants completed self-report measures to assess intervention satisfaction, perceived usability, and preliminary efficacy. Additional perspectives were captured via qualitative exit interviews., Results: In total, 100% of retained participants ( n  = 9) engaged with the text messages throughout the entire 8-week period. Mean scores of 27 (SD   = 5.05) on the Client Satisfaction Questionnaire at the end of 8-week period indicated a high degree of satisfaction with the text-based intervention. The average rating on the System Usability Scale was 65.3 at the end of the 8-week program, suggesting that the intervention was relatively easy to use. Participants also endorsed positive experiences with the intervention during qualitative interviews. Clinical improvements were observed across the intervention period., Conclusions: Preliminary findings from this pilot suggest that the content and delivery method of this combined web- and text message-based personalized feedback intervention is perceived by patients as feasible and acceptable. Leveraging digital health platforms to augment buprenorphine has potential for high scalability and impact to reduce opioid use, increase adherence/retention to treatment, and prevent future incidence of overdose. Future work will evaluate the efficacy of the intervention in a randomized clinical trial design., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The "Safety in Dementia" (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown., Objective: Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access., Methods: The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost., Results: The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled., Conclusions: The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources., Trial Registration: ClinicalTrials.gov NCT05173922; https://clinicaltrials.gov/ct2/show/NCT05173922., International Registered Report Identifier (irrid): DERR1-10.2196/43702., (©Virginia McCarthy, Jennifer Portz, Stacy M Fischer, Emily Greenway, Rachel L Johnson, Christopher E Knoepke, Daniel D Matlock, Faris Omeragic, Ryan A Peterson, Megan L Ranney, Marian E Betz. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 31.01.2023.)

Firearm-related injury and death is a serious public health issue in the U.S. As more Americans consume news and media online, there is growing interest in using these channels to prevent firearm-related harms. Understanding the firearm-related narratives to which consumers are exposed is foundational to this work. This research used the browsing behavior of a representative sample of American adults to identify seven firearm-related content "ecosystems" (defined as naturally occurring networks of channels watched by the same users) on YouTube; we then described the demographics and internet search patterns of users affiliated with each ecosystem. Over the 9-month study period, 72,205 panelists had 16,803,075 person-video encounters with 7,274,093 videos. Among these, 282,419 were related to firearms. Using fast greedy clustering, we partitioned users and channel interactions into seven distinct channel-based content ecosystems that reached more than 1/1000 YouTube users per day. These ecosystems were diverse in reach, users, and content (e.g., guns for self-protection, guns for fun). On average, 0.5% of panelists performed a firearm-related internet search on a given day. The vast majority of searches were related to mass shootings or police-involved shootings (e.g., "active shooter"), and virtually none were about more common firearm harm such as suicide. Searches for firearm safety information were most common among panelists affiliated with the "Hunting & Fishing" and "Guns & Gear" ecosystems, which were watched primarily by older, white men. These findings identify an opportunity for analyzing firearm-related narratives and tailoring firearm safety messaging for users affiliated with specific online content ecosystems., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Megan L. Ranney is a Senior Strategic Advisor (volunteer) for AFFIRM at the Aspen Institute, and serves on the Board of Directors for the Nonviolence Institute in Providence, RI. Frederica R. Conrey is employed by Harmony Labs and Rory Smith was employed by Harmony Labs when this research was conducted., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The medical community recognizes that firearm injury is a public health problem. Yet we lack both the tools for and the implementation of evidence-based firearm injury screening and counseling techniques. One reason for these deficits is the lack of clinical training related to engaging patients in firearm injury risk reduction. In this issue, Rickert et al describe a pre-post evaluation of a 2-part firearm injury prevention training curriculum for first-year medical residents at a single academic medical center. Their manuscript serves an important, but still preliminary, step forward for the field of postgraduate medical education on firearm injury and its prevention. Important elements of this project and paper consist of the inclusion of multiple medical disciplines and the use of standardized patients to evaluate participants' learning. This project also points to the need for further growth. We must commit to consistently and conscientiously framing injuries from guns not as "gun violence" but rather as "firearm injuries" to ensure that they are considered squarely in both the public health space and the clinical space. An ideal curriculum would also highlight the importance of trauma-informed care, cultural competency, and antiracist medical practice while countering implicit biases (e.g., toward gun owners, victims of firearm violence, perpetrators of violence). It should address barriers, as well as facilitators, to change. And most importantly, future educational work must evaluate the effect of these trainings on actual clinical practice-and, even better, the efficacy of education in changing behavior and patient-level outcomes., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Symptom checkers are clinical decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnostic and triage advice and assist users in seeking the appropriate level of care. Little evidence is available regarding their diagnostic and triage accuracy with direct use by patients for urgent conditions., Objective: The aim of this study is to determine the diagnostic and triage accuracy and usability of a symptom checker in use by patients presenting to an emergency department (ED)., Methods: We recruited a convenience sample of English-speaking patients presenting for care in an urban ED. Each consenting patient used a leading symptom checker from Ada Health before the ED evaluation. Diagnostic accuracy was evaluated by comparing the symptom checker's diagnoses and those of 3 independent emergency physicians viewing the patient-entered symptom data, with the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. The patients completed a usability survey based on the Technology Acceptance Model., Results: A total of 40 (80%) of the 50 participants approached completed the symptom checker assessment and usability survey. Their mean age was 39.3 (SD 15.9; range 18-76) years, and they were 65% (26/40) female, 68% (27/40) White, 48% (19/40) Hispanic or Latino, and 13% (5/40) Black or African American. Some cases had missing data or a lack of a clear ED diagnosis; 75% (30/40) were included in the analysis of diagnosis, and 93% (37/40) for triage. The sensitivity for at least one of the final ED diagnoses by Ada (based on its top 5 diagnoses) was 70% (95% CI 54%-86%), close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated the Ada triage decisions as 62% (23/37) fully agree and 24% (9/37) safe but too cautious. It was rated as unsafe and too risky in 22% (8/37) of cases by at least one physician, in 14% (5/37) of cases by at least two physicians, and in 5% (2/37) of cases by all 3 physicians. Usability was rated highly; participants agreed or strongly agreed with the 7 Technology Acceptance Model usability questions with a mean score of 84.6%, although "satisfaction" and "enjoyment" were rated low., Conclusions: This study provides preliminary evidence that a symptom checker can provide acceptable usability and diagnostic accuracy for patients with various urgent conditions. A total of 14% (5/37) of symptom checker triage recommendations were deemed unsafe and too risky by at least two physicians based on the symptoms recorded, similar to the results of studies on telephone and nurse triage. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments., (©Hamish S F Fraser, Gregory Cohan, Christopher Koehler, Jared Anderson, Alexis Lawrence, John Pateña, Ian Bacher, Megan L Ranney. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 19.09.2022.)

Objective: Mood disorders complicated by suicidal ideation (SI) frequently present to the emergency department (ED) for care. Currently, patients with SI in the ED do not typically receive targeted interventions. Ketamine may have a role in treating SI within the ED because subanesthetic doses have rapid-acting antidepressant and antisuicidal properties., Methods: This single-arm, open-label feasibility study enrolled 14 participants from the ED with acute SI who were awaiting voluntary admission to inpatient psychiatry to receive ketamine at 0.5 mg/kg, administered intravenously. Participants were assessed post administration to evaluate feasibility of administration in the ED and short-term effectiveness. Feasibility was determined by acceptability by patients and physicians as well as tolerability and ability to recruit participants into the study. Efficacy was assessed based on changes in (1) self-reported mood and (2) suicidal ideation pre- and postinfusion of ketamine., Results: All patients reported severe depression and active SI at baseline. No serious adverse events were reported, and acceptability was rated highly by both participants and physicians (>70%). Two hours after receiving ketamine 0.5 mg/kg, the mean SI and somatic symptom burden were decreased compared to baseline ( P  < 0.001 and P  = 0.005, respectively), and the mean self-reported mood was increased ( P  = 0.006). Improvements in mood and decreases in suicidality persisted at 6 hours., Conclusions: Overall, ketamine was well tolerated, considered feasible by both participants and physicians, and demonstrated short-term efficacy. There is a growing body of evidence demonstrating the feasibility of ketamine administration in the ED, and larger randomized trials should be conducted to establish treatment recommendations for patients with SI in the ED., Competing Interests: None of the study authors have any conflicts of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Drug overdose and firearm injury are two of the United States (US) most unrelenting public health crises, both of which have been compounded by the COVID-19 pandemic. Programs and policies typically focus on each epidemic, alone, which may produce less efficient interventions if overlap does exist. The objective is to examine whether drug overdose correlates with and is associated with firearm injury at the census tract level while controlling for neighborhood characteristics., Methods: An ecological study of census tracts in Indianapolis, Indiana from 2018 to 2020. Population rates per 100,000 and census tracts with the highest overlap of overdose and firearm injury were identified based on spatial clusters. Bivariate association between census tract characteristic and drug overdose and firearm violence rate within spatial clusters. Zero-inflated negative binominal regression was used to estimate if the drug overdose activity is associated with higher future firearm injury., Results: In high overdose-high firearm injury census tracts, rates of firearm injury and drug overdose are two times higher compared to city wide rates. Indicators of structural disadvantage and structural racism are higher in high overdose-high firearm injury census tracts compared to city-wide averages. Drug overdoses are associated with higher rates of firearm injury in the following year (IRR: 1.004, 95% CI 1.001, 1.007, p < 0.05), adjusting for census tract characteristics and spatial dependence., Conclusions: Drug overdose and firearm injury co-spatially concentrate within census tracts. Moreover, drug overdoses are associated with future firearm injury. Interventions to reduce firearm injuries and drug overdoses should be a co-response in high drug overdose-high firearm injury communities., (© 2022. The Author(s).)

Social media integration into research has increased, and 92% of American social media participants state they would share their data with researchers. Yet, the potential of these data to transform health outcomes has not been fully realized, and the way clinical research is performed has been held back. The use of these technologies in research is dependent on the investigators' awareness of their potential and their ability to innovate within regulatory and institutional guidelines. The Brown-Lifespan Center for Digital Health has launched an initiative to address these challenges and provide a helpful framework to expand social media use in clinical research., (©Elizabeth M Goldberg, Rochelle K Rosen, Don S Dizon, Kirsten J Langdon, Natalie M Davoodi, Tyler B Wray, Nicole R Nugent, Shira I Dunsiger, Megan L Ranney. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 13.06.2022.)

Purpose of Reviews: The purpose of this review was to summarize the current state of the literature on the use of "mHealth" (the use of mobile devices for health promotion) for injury prevention and control., Recent Findings: mHealth is being used to measure, predict, and prevent the full spectrum of injuries. However, most literature remains preliminary or in a pilot stage. Use of best-of-class design principles (e.g., user-centered design, theory-based development) is uncommon, and wide-scale dissemination of effective monitoring or intervention tools is rare., Summary: mHealth for injury prevention holds promise, but further work is needed across the full spectrum of development and translation., Competing Interests: Competing InterestsM. Kit Delgado reports contract payments, grant, and philanthropic donation from the FDA, CDC, and the Abramson Family Foundation, respectively, since the initial planning of the work. Dr. Delgado further reports grants from NIH, PCORI, and USDOT within the past 36 months. Lindsay M. Orchowski, Elizabeth Stettenbauer and Katherine Yao declare no conflicts of interest since the initial planning of the work, nor within the past 36 months., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals., Method: In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list., Results: This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury., Conclusions: Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities., Competing Interests: Other disclosures: Several authors have received consultant payments from organizations to develop firearm injury risk reduction training programs or to serve as firearms instructors. The authors have no potential conflicts of interest to disclose.

Background: Predictive analytic models, including machine learning (ML) models, are increasingly integrated into electronic health record (EHR)-based decision support tools for clinicians. These models have the potential to improve care, but are challenging to internally validate, implement, and maintain over the long term. Principles of ML operations (MLOps) may inform development of infrastructure to support the entire ML lifecycle, from feature selection to long-term model deployment and retraining., Objectives: This study aimed to present the conceptual prototypes for a novel predictive model management system and to evaluate the acceptability of the system among three groups of end users., Methods: Based on principles of user-centered software design, human-computer interaction, and ethical design, we created graphical prototypes of a web-based MLOps interface to support the construction, deployment, and maintenance of models using EHR data. To assess the acceptability of the interface, we conducted semistructured user interviews with three groups of users (health informaticians, clinical and data stakeholders, chief information officers) and evaluated preliminary usability using the System Usability Scale (SUS). We subsequently revised prototypes based on user input and developed user case studies., Results: Our prototypes include design frameworks for feature selection, model training, deployment, long-term maintenance, visualization over time, and cross-functional collaboration. Users were able to complete 71% of prompted tasks without assistance. The average SUS score of the initial prototype was 75.8 out of 100, translating to a percentile range of 70 to 79, a letter grade of B, and an adjective rating of "good." We reviewed persona-based case studies that illustrate functionalities of this novel prototype., Conclusion: The initial graphical prototypes of this MLOps system are preliminarily usable and demonstrate an unmet need within the clinical informatics landscape., Competing Interests: M.L.R. reports all support from NIGMS (grant no.: U54GM115677) for early phases of this work. S.L.S. reports all support from Brown University Summer Assistantship Fund., (Thieme. All rights reserved.)

Background: Buprenorphine-naloxone is an evidence-based treatment for opioid use disorder (OUD). Despite its efficacy, nearly half of patients discontinue treatment prematurely. Novel intervention strategies that may be delivered outside of traditional treatment settings are needed to support buprenorphine uptake and maintenance. The goal of this study was to elucidate key elements surrounding the acceptability/feasibility and structure of an interactive computer- and text message-delivered personalized feedback intervention for adults initiating outpatient buprenorphine treatment., Methods: Twenty-four adults engaged in treatment at two outpatient addiction treatment centers completed semistructured interviews exploring preferences around digital health interventions. Trained interviewers conducted interviews, the study audio-recorded them, and a professional agency transcribed them verbatim. The research team iteratively developed a coding structure using thematic and content analysis and entered it into a framework matrix. The team double coded each transcript., Results: The sample was balanced by gender, primary type of opioid use (prescription pills; heroin/fentanyl), and phase of recovery [early (≤8 weeks of treatment) vs. late (>8 weeks of treatment)]. The study reached saturation after 24 interviews (mean age = 38.9; 70.8% white; 8.3% Hispanic/Latino). (1) Acceptability/feasibility themes: A computer- and text message-based intervention that incorporates a motivational- and distress tolerance-based framework is highly acceptable. Presentation of material, including the length of the intervention, is effective in facilitating learning. The center should offer the intervention to individuals entering treatment and they should have the flexibility to complete the intervention at the center or in private from their own home. The use of technology for intervention delivery helps to overcome fears of judgment stemming from stigmatizing experiences. (2) Structural themes: The text message intervention should deliver both predetermined (automatic) and on demand messages. Two to three messages per day (morning and early evening), with the option to elicit additional messages as needed, would be ideal. The messages must be personalized. Incorporating multimedia such as emojis, gifs, and links to videos will increase interactivity., Conclusions: Overall, adults engaged in outpatient buprenorphine treatment were receptive to an interactive computer- and text messaged-delivered personalized feedback intervention to support recovery. Incorporating thematic results on suggested structural changes may increase the usability of this intervention to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: The purpose of this study was to describe the feasibility, cost-effectiveness, and generalizability of a strategy for recruiting adolescents into research studies through social media., Methods: We designed and tested six Instagram advertisements (ads) with a combination of Instagram campaign objectives (Traffic vs. Reach) and types of placement (Story vs. Feed). The goal was to obtain remote assent and screen for a larger remote behavioral intervention study. The eligibility criteria for screening were being aged 13-17 years, residing in the United States, and English-speaking. The eligibility for the larger study was past year cybervictimization and smartphone ownership. A target sample was 80 participants, randomly assigned to a control or intervention group and followed up for 16 weeks. Recruitment rates and cost-per-enrolled participant with different advertising strategies, demographics, and retention were examined using descriptive statistics., Results: The six ads were run over 907.5 hours, generating 1,069,747 impressions, 2,051 click-throughs, and 663 completed screening surveys. Of 493 eligible participants, 24.4% assented to participate, 69.4% completed enrollment, and 4.8% dropped/withdrew after randomization. Average advertising costs were $52/participant; the lowest-cost strategy (Traffic campaign + Feed ad placement) was $19/enrolled participant. The study sample was largely white (81.3%), non-Hispanic (87.5%), and female (77.5%) with an average age of 15.33 years. Nearly half of the participants were identified as lesbian, gay, or bisexual. More than 96% of participants were retained at the 16-week follow-up., Conclusions: Instagram can be a feasible and cost-effective way to recruit adolescents for a remote study. This method may be ideal for recruiting hard-to-reach audiences., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Between 15% and 70% of adolescents report experiencing cybervictimization. Cybervictimization is associated with multiple negative consequences, including depressed mood. Few validated, easily disseminated interventions exist to prevent cybervictimization and its consequences. With over 97% of adolescents using social media (such as YouTube, Facebook, Instagram, or Snapchat), recruiting and delivering a prevention intervention through social media and apps may improve accessibility of prevention tools for at-risk youth., Objective: This study aims to evaluate the feasibility and acceptability of and obtain preliminary outcome data on IMPACT (Intervention Media to Prevent Adolescent Cyber-Conflict Through Technology), a brief, remote app-based intervention to prevent and reduce the effect of cyberbullying., Methods: From January 30, 2020, to May 3, 2020, a national sample of 80 adolescents with a history of past-year cybervictimization was recruited through Instagram for a randomized control trial of IMPACT, a brief, remote research assistant-led intervention and a fully automated app-based program, versus enhanced web-based resources (control). Feasibility and acceptability were measured by consent, daily use, and validated surveys. Although not powered for efficacy, outcomes (victimization, bystander self-efficacy, and well-being) were measured using validated measures at 8 and 16 weeks and evaluated using a series of longitudinal mixed models., Results: Regarding feasibility, 24.5% (121/494) of eligible participants provided contact information; of these, 69.4% (84/121) completed full enrollment procedures. Of the participants enrolled, 45% (36/80) were randomized into the IMPACT intervention and 55% (44/80) into the enhanced web-based resources groups. All participants randomized to the intervention condition completed the remote intervention session, and 89% (77/80) of the daily prompts were answered. The retention rate was 99% (79/80) at 8 weeks and 96% (77/80) at 16 weeks for all participants. Regarding acceptability, 100% (36/36) of the intervention participants were at least moderately satisfied with IMPACT overall, and 92% (33/36) of the participants were at least moderately satisfied with the app. At both 8 and 16 weeks, well-being was significantly higher (β=1.17, SE 0.87, P=.02 at 8 weeks and β=3.24, SE 0.95, P<.001 at 16 weeks) and psychological stress was lower (β=-.66, SE 0.08, P=.04 at 8 weeks and β=-.89, SE 0.09, P<.001 at 16 weeks) among IMPACT users than among control group users. Participants in the intervention group attempted significantly more bystander interventions than those in the control group at 8 weeks (β=.82, SE 0.42; P=.02)., Conclusions: This remote app-based intervention for victims of cyberbullying was feasible and acceptable, increased overall well-being and bystander interventions, and decreased psychological stress. Our findings are especially noteworthy given that the trial took place during the COVID-19 pandemic. The use of Instagram to recruit adolescents can be a successful strategy for identifying and intervening with those at the highest risk of cybervictimization., Trial Registration: ClinicalTrials.gov NCT04259216; http://clinicaltrials.gov/ct2/show/NCT04259216., (©Emily R Kutok, Shira Dunsiger, John V Patena, Nicole R Nugent, Alison Riese, Rochelle K Rosen, Megan L Ranney. Originally published in JMIR Mental Health (https://mental.jmir.org), 15.09.2021.)

Objectives: The aim of this study was to understand the prevalence of alcohol and other substance use among teenagers in generalized samples., Methods: This study compared the alcohol and other substance use of adolescents enrolled in a screening study across 16 Pediatric Emergency Care Applied Research Network emergency departments (EDs) (ASSESS) with those sampled in 2 nationally representative surveys, the Youth Risk Behavior Surveillance System (YRBSS) and the National Survey of Drug Use and Health (NSDUH). The analysis includes 3362 ASSESS participants and 11,142 YRBSS and 12,086 NSDUH respondents., Results: The ASSESS patients had a similar profile to the NSDUH sample, with small differences in marijuana and cocaine use and age at first tobacco smoking and smoking within the last 30 days and higher use of snuff or chewing tobacco. The YRBSS participants had higher rates of using marijuana, snuff/chewing tobacco, methamphetamine, and hallucinogens and higher smoking rates compared with ASSESS and NSDUH., Conclusions: Adolescents visiting Pediatric Emergency Care Applied Research Network EDs have substantial rates of substance use, similar to other nationally representative studies on this topic, although not as high as a school-based survey. Future ED studies should continue to investigate adolescent substance use, including exploring optimal methods of survey administration., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Cybervictimization among adolescents is associated with multiple negative mental health consequences. Although pediatricians often screen for cyberbullying, validated and acceptable programs to reduce the frequency and impact of adolescent cybervictimization are lacking., Objective: This study uses agile qualitative methods to refine and evaluate the acceptability of a mixed-modality intervention, initiated within the context of usual pediatric care, for adolescents with a history of cyberharassment and cyberbullying victimization., Methods: Three groups of adolescents were successively recruited from an urban primary care clinic to participate in three consecutive iterations (1, 2, and 3) of the program, which consisted of a brief in-clinic intervention followed by 8 weeks of daily, automated SMS text messaging. After 2 weeks of messaging, iteration 1 (I1) participants completed semistructured interviews regarding intervention experiences. Participant feedback was evaluated via framework matrix analysis to guide changes to the program for iteration 2 (I2). Feedback from 2-week interviews of I2 participants was similarly used to improve the program before initiating iteration 3 (I3). Participants in all 3 iterations completed the interviews after completing the program (8 weeks). Daily response rates assessed participant engagement, and satisfaction questionnaires assessed acceptability., Results: A total of 19 adolescents (aged 13-17 years) reporting past-year cybervictimization were enrolled: 7 in I1, 4 in I2, and 8 in I3. Demographic variables included the following: a mean age of 15 (SD 1.5) years; 58% (11/19) female, 42% (8/19) male, 63% (12/19) Hispanic, 37% (7/19) non-Hispanic, 79% (15/19) people of color, and 21% (4/19) White. A total of 73% (14/19) self-identified as having a low socioeconomic status, and 37% (7/19) self-identified as lesbian, gay, or bisexual. The average past 12-month cybervictimization score at baseline was 8.2 (SD 6.58; range 2-26). Participant feedback was used to iteratively refine intervention content and design. For example, participants in I1 recommended that the scope of the intervention be expanded to include web-based conflicts and drama, rather than narrowly focusing on cyberbullying prevention. On the basis of this feedback, the I2 content was shifted toward more general de-escalation skills and bystander empowerment. Overall, 88.34% (940/1064) of the daily queries sent to participants across all 3 iterations received a reply. Participant satisfaction improved considerably with each iteration; 0% (0/7) of I1 participants rated the overall quality of Intervention to Prevent Adolescent Cybervictimization with Text message as excellent, compared to 50% (2/4) of I2 participants and 86% (6/7) of I3 participants. Engagement also improved between the first and third iterations, with participants replying to 59.9% (235/392) of messages in I1, compared to 79.9% (358/488) of messages in I3., Conclusions: This study shows the value of structured participant feedback gathered in an agile intervention refinement methodology for the development of a technology-based intervention targeting adolescents., (©Megan L Ranney, Sarah K Pittman, Isabelle Moseley, Kristen E Morgan, Alison Riese, Michele Ybarra, Rebecca Cunningham, Rochelle Rosen. Originally published in JMIR Formative Research (https://formative.jmir.org), 27.08.2021.)

Background: Low-income women are less likely to breastfeed than high-income women. Technology-based interventions demonstrate promise in decreasing health disparities. We assessed whether increased use of breastfeeding smartphone applications (apps) impacts breastfeeding rates for low-income women. Materials and Methods: This is a secondary analysis of a randomized control trial (RCT), including nulliparous, low-income women. Women were randomized to one of two novel apps: control app containing digital breastfeeding handouts and BreastFeeding Friend (BFF), an interactive app containing on-demand breastfeeding educational and video content. App usage was securely tracked. The highest quartile of BFF and control app users were combined and compared to the lowest quartile of app users. The primary outcome was breastfeeding initiation. Secondary outcomes included breastfeeding outcomes and resource preferences through 6 months. Results: In the RCT, BFF and control app median uses were 15 (interquartile range [IQR] 4-24) and 9 (IQR 5-19) ( p  = 0.1), respectively. Breastfeeding initiation did not differ with app usage (84.1% in highest quartile versus 78.2% for lowest quartile; p  = 0.5). Rates of sustained and exclusive breastfeeding through 6 months were similar between groups. Among both groups, smartphone apps were the most preferred breastfeeding resource at 6 weeks. Low quartile users also preferred alternative online breastfeeding resources: >50% of all users preferred technology-based breastfeeding resources. Conclusions: Increased usage of breastfeeding apps did not improve breastfeeding rates among low-income women. However, technology-based resources were the most preferred breastfeeding resource after hospital discharge, indicating ongoing development of technology-based interventions has potential to increase breastfeeding in this high-needs population. clinicaltrials.gov (NCT03167073).

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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

Competing Interests: Competing interests: EMG reports grants from the National Institute on Aging (K76AG059983) and the Brown Physicians Academic Assessment Research Award (PI: EMG) during the conduct of the study. MLR reports funding from the Warren Alpert Endowed Professorship of Emergency Medicine and the Brown-Lifespan Center for Digital Health during the conduct of the study.

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.

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

Background: Twitter has emerged as a novel way for physicians to share ideas and advocate for policy change. #ThisIsOurLane (firearm injury) and #GetUsPPE (COVID-19) are examples of nationwide health care-led Twitter campaigns that went viral. Health care-initiated Twitter hashtags regarding major public health topics have gained national attention, but their content has not been systematically examined., Objective: We hypothesized that Twitter discourse on two epidemics (firearm injury and COVID-19) would differ between tweets with health care-initiated hashtags (#ThisIsOurLane and #GetUsPPE) versus those with non-health care-initiated hashtags (#GunViolence and #COVID19)., Methods: Using natural language processing, we compared content, affect, and authorship of a random 1% of tweets using #ThisIsOurLane (Nov 2018-Oct 2019) and #GetUsPPE (March-May 2020), compared to #GunViolence and #COVID19 tweets, respectively. We extracted the relative frequency of single words and phrases and created two sets of features: (1) an open-vocabulary feature set to create 50 data-driven-determined word clusters to evaluate the content of tweets; and (2) a closed-vocabulary feature for psycholinguistic categorization among case and comparator tweets. In accordance with conventional linguistic analysis, we used a P<.001, after adjusting for multiple comparisons using the Bonferroni correction, to identify potentially meaningful correlations between language features and outcomes., Results: In total, 67% (n=4828) of #ThisIsOurLane tweets and 36.6% (n=7907) of #GetUsPPE tweets were authored by health care professionals, compared to 16% (n=1152) of #GunViolence and 9.8% (n=2117) of #COVID19 tweets. Tweets using #ThisIsOurLane and #GetUsPPE were more likely to contain health care-specific language; more language denoting positive emotions, affiliation, and group identity; and more action-oriented content compared to tweets with #GunViolence or #COVID19, respectively., Conclusions: Tweets with health care-led hashtags expressed more positivity and more action-oriented language than the comparison hashtags. As social media is increasingly used for news discourse, public education, and grassroots organizing, the public health community can take advantage of social media's broad reach to amplify truthful, actionable messages around public health issues., (©Ayotomiwa Ojo, Sharath Chandra Guntuku, Margaret Zheng, Rinad S Beidas, Megan L Ranney. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 06.01.2021.)

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

Objective: To examine the effect of a novel smartphone application (app)-BreastFeeding Friend (BFF)-on breastfeeding rates among low-income first-time mothers planning exclusive breastfeeding. Methods: A recent randomized controlled trial (RCT) randomized low-income first-time mothers to BFF or control app. BFF contained breastfeeding education and videos. The control app contained digital breastfeeding handouts. Outcomes included breastfeeding rates until 6 months postpartum and patient-reported best breastfeeding resource. After enrollment, nearly half the participants reported planning formula feeding after breastfeeding initiation, potentially confounding the RCT results. In this secondary analysis, women planning formula feeding were excluded. Outcomes between study groups were compared by intent-to-treat. Results: Of the original 170 participants, 41 in BFF and 46 in control group planned exclusively breastfeeding and were included. Exclusive breastfeeding rates were similar from 2 days postpartum (BFF: n  = 19 [48.7%] versus control app: n  = 21 [46.7%]; relative risk [RR] = 1.04, 95% confidence interval, CI = 0.67-1.63]) until 6 months postpartum. At 6 weeks postpartum, the majority of BFF users ( n  = 23 [62.2%]) believed an app provided the best breastfeeding support compared with 39% of control app users ( n  = 16; RR = 1.59 [95% CI = 1.01-2.52]). BFF users were 2.5 times more likely to deny having breastfeeding challenges compared with control app users ( n  = 12 [42.9%] versus n  = 6 [16.7%]; RR = 2.57 [95% CI = 1.10-6.00]). Conclusion: BFF reduced self-reported breastfeeding challenges and was perceived as the best breastfeeding resource at home but did not increase breastfeeding rates among low-income first-time mothers desiring to exclusively breastfeed. BFF shows promise but must be further optimized to ultimately impact breastfeeding rates. Trial Identification Number: NCT03167073.

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