Talking about firearm injury prevention with patients: a survey of medical residents.

BackgroundFirearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention.MethodA 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers.ResultsThe most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms.ConclusionsEducation on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist

Incidence, Distribution, and Lethality of Firearm Injuries in California From 2005 to 2015.

ImportanceLittle is known about nonfatal firearm injuries in the United States, and national estimates based on emergency department samples may not be accurate.ObjectiveTo describe the incidence and distribution of nonfatal firearm injuries and estimate case fatality ratios (CFRs) for firearm injuries by external cause of injury code within California overall and by race/ethnicity, including an assessment of trends over time and geographic variation within the state.Design, setting, and participantsThis serial cross-sectional study used complete statewide data for firearm-related mortality, emergency department visits, and hospitalizations among California residents from January 1, 2005, through December 31, 2015, to analyze incidence, distribution, and CFRs of firearm injury. Data were analyzed from 2018 to 2019.ExposuresAll individuals in California with a firearm injury based on International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes were included.Main outcomes and measuresCounts and rates of nonfatal firearm injuries overall and stratified by external cause, sex, and race/ethnicity; total and clinical CFRs. Clinical CFR was calculated based on individuals treated in emergency departments or hospitals.ResultsOver the study period, there were 81 085 firearm-related emergency department visits and hospitalizations among individuals with a mean (SD) age of 27.5 (11.9) years, 72 567 (89.6%) of whom were men. Nonfatal firearm injuries in California decreased by 38.1% between 2005 and 2015, driven by a 46.4% decrease in assaultive injuries. Self-inflicted injuries and unintentional injuries remained relatively stable. The overall CFR for firearm injuries increased from 27.6% in 2005 to 32.2% in 2015 for a relative increase of 20.7%, while the clinical CFR remained stable between 7.0% and 9.0%.Conclusions and relevanceThese findings suggest that although the number of firearm injuries has decreased in California, the lethality of these injuries has not. Similar studies from other states could provide more information about these trends nationwide

Readmission risk and costs of firearm injuries in the United States, 2010-2015.

BACKGROUND:In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms. METHODS:We used the Nationwide Readmission Database 2010-2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs. RESULTS:Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5$32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this

Evolution of mosquito preference for humans linked to an odorant receptor

Female mosquitoes are major vectors of human disease and the most dangerous are those that preferentially bite humans. A ‘domestic’ form of the mosquito Aedes aegypti has evolved to specialize in biting humans and is the major worldwide vector of dengue, yellow fever, and Chikungunya viruses. The domestic form coexists with an ancestral, animal-biting ‘forest’ form along the coast of Kenya. We collected the two forms, established laboratory colonies, and document striking divergence in preference for human versus animal odour. We further show that the evolution of preference for human odour in domestic mosquitoes is tightly linked to increases in the expression and ligand-sensitivity of the odorant receptor AaegOr4, which we found recognises a compound present at high levels in human odour. Our results provide a rare example of a gene contributing to behavioural evolution and provide insight into how disease-vectoring mosquitoes came to specialise on humans

Hospital Costs and Fatality Rates of Traumatic Assaults by Mechanism in the US, 2016-2018

IMPORTANCE: Estimates of the total economic cost of firearm violence are important in drawing attention to this public health issue; however, studies that consider violence more broadly are needed to further the understanding of the extent to which such costs can be avoided. OBJECTIVES: To estimate the association of firearm assaults with US hospital costs and deaths compared with other assault types. DESIGN, SETTING, AND PARTICIPANTS: The 2016-2018 US Nationwide Emergency Department Sample and National Inpatient Sample, Healthcare Cost and Utilization Project were used in this cross-sectional study of emergency department (ED) and inpatient admissions for assaults involving a firearm, sharp object, blunt object, or bodily force identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Differences in ED and inpatient costs (2020 US dollars) across mechanisms were estimated using ordinary least-squares regression with and without adjustments for year and hospital, patient, and injury characteristics. The Centers for Disease Control and Prevention underlying cause of death data were used to estimate national death rates and hospital case-fatality rates across mechanisms. Cost analysis used a weighted sample. National death rates and hospital case-fatality rates used US resident death certificates, covering 976 million person-years. Hospital case-fatality rates also used nationally weighted ED records covering 2.7 million admissions. Data analysis was conducted from March 1, 2021, to March 31, 2022. EXPOSURE: The primary exposure was the mechanism used in the assault. MAIN OUTCOMES AND MEASURES: Emergency department and inpatient costs per record. National death rates and hospital case-fatality rates. RESULTS: Overall, 2.4 million ED visits and 184 040 inpatient admissions for assault were included. Across all mechanisms, the mean age of the population was 32.7 (95% CI, 32.6-32.9) years in the ED and 36.4 (95% CI, 36.2-36.7) years in the inpatient setting; 41.9% (95% CI, 41.2%-42.5%) were female in the ED, and 19.1% (95% CI, 18.6%-19.6%) of inpatients were female. Most assaults recorded in the ED involved publicly insured or uninsured patients and hospitals in the Southern US. Emergency department costs were $678 (95$657-$699) for bodily force,$861 (95% CI, $813-$910) for blunt object, $996 (95$925-$1067) for sharp object, and$1388 (95% CI, $1254-$1522) for firearm assaults. Corresponding inpatient costs were $14 702 (95$14 178-$15 227) for bodily force,$17 906 (95% CI, $16 888-$18 923) for blunt object, $19 265 (95$18 475-$20 055) for sharp object, and$34 949 (95% CI, $33 654-$36 244) for firearm assaults. National death rates per 100 000 were 0.04 (95% CI, 0.03-0.04) for bodily force, 0.03 (95% CI, 0.03-0.03) for blunt object, 0.54 (95% CI, 0.52-0.55) for sharp object, and 4.40 (95% CI, 4.36-4.44) for firearm assaults. Hospital case fatality rates were 0.01% (95% CI, 0.009%-0.012%) for bodily force, 0.05% (95% CI, 0.04%-0.06%) for blunt object, 1.05% (95% CI, 1.00%-1.09%) for sharp object, and 15.26% (95% CI, 15.04%-15.49%) for firearm assaults. In regression analysis, ED costs for firearm assaults were 59% to 99% higher than costs for nonfirearm assaults, and inpatient costs were 67% to 118% higher. CONCLUSIONS AND RELEVANCE: The findings of this study suggest that it may be useful for policies aimed at reducing the costs of firearm violence to consider violence more broadly to understand the extent to which costs can be avoided

Patient and Hospital Characteristics Associated with Admission Among Patients With Minor Isolated Extremity Firearm Injuries: A Propensity-Matched Analysis

Objective:. To quantify the association between insurance and hospital admission following minor isolated extremity firearm injury. Background:. The association between insurance and injury admission has not been examined. Methods:. This was an observational retrospective cohort study of minor isolated extremity firearm injury captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases in 6 states (New York, Arkansas, Wisconsin, Massachusetts, Florida, and Maryland) from 2016 to 2017 among patients aged 16 years or older. The primary exposure was insurance. Admitted patients were propensity score matched to nonadmitted patients on age, extremity Abbreviated Injury Score, and Elixhauser Comorbidity Index with exact matching within hospital to adjust for selection bias. A general estimating equation logistic regression estimated the association between insurance and odds of admission in the matched cohort while controlling for sex, race, injury intent, injury type, hospital profit type, and trauma center designation with observations clustered by propensity score-matched pairs within hospital. Results:. A total of 8151 patients presented to hospital with a minor isolated extremity firearm injury between 2016 and 2017 in 6 states. Patients were 88.0% male, 56.6% Black, and 71.7% aged 16 to 36 years old, and 22.1% were admitted. A total of 2090 patients were matched on propensity for admission. Privately insured matched patients had 1.70 higher adjusted odds of admission and 95% confidence interval of 1.30 to 2.22, compared with uninsured after adjusting for patient and hospital characteristics. Conclusions:. Insurance was associated with hospital admission for minor isolated extremity firearm injury

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III