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Article 1
Firearm deaths in America: Can we learn from 462,000 lives lost? Resnick S, Smith RN, Beard JH, Holena D, Reilly PM, Schwab CW, Seamon MJ. Ann of Surgery. 2017 Sept; 266(3): 432-444.
Little scientific research exists regarding firearm injury prevention in light of the large healthcare burden of firearm-related injury and mortality. Due to the Dickey Amendment in 1996 banning CDC funds for research into gun control advocacy, gun violence publications decreased by 64% between 1998-2012. Increased media coverage of recent mass shooting events has prompted a re-invigorated focus on firearm-related violence as a major public health issue.
This study by Resnick, et al, represents sound, scientific evaluation of whether individual state firearm legislation correlates with firearm-related fatality over a 15-year study period. Using state scorecards from both the Brady Campaign/Law Center to Prevent Gun Violence (BC/LC) as well as the National Rifle Association (NRA), each state was classified and given a grade “A-F” based on their legislation. While the BC/LC assigned an “A” grade to most restrictive legislation, the NRA assigns “A” grades to the least restrictive legislation. This study dichotomized states into “A-D” and “F” to achieve a “some versus none” analysis of all scorecards over the 15-year period. Using the CDC Web-Based Injury Statistics Query and Reporting System (WISQARS), firearm mortality statistics were collected for analysis.
The authors found that over the study period, 462,043 Americans were killed by firearms; suicides represented the majority of deaths, and Black Americans and males were more commonly killed. Statistically significant differences in firearm-related fatalities were detected between “A-D” and “F” states with respect to overall fatalities, as well as female, male, white, unintentional, pediatric, and suicide deaths. This was true for both the BC/LC classification as well as the NRA grading system. Conversely, there was no correlation between Black firearm-related fatalities or homicides with analysis of either the NRA or BC/LC scoring of state legislation.
While addressing a politically-charged topic, this study identified that restrictive state firearm legislation was associated with a decrease in unintentional, pediatric, suicide, and overall firearm-related fatalities, with no effect on homicides or Black American deaths. Some caution must be taken in interpreting the results; in order to offset political bias, the authors used two organizations to analyze state legislation; however, these scorecards are published by groups with political agendas and were dichotomized into an “all or none” analysis. In addition, the WISQUARS database reports only firearm deaths, and while the public health burden is staggering with 462,043 deaths, the total injury burden attributable to firearm violence is much higher.
Article 2
Nationwide trends in mortality following penetrating trauma: Are we up for the challenge? Sakran JV, Mehta A, Fransman R, Nathens AB, Joseph B, Kent A, Haut ER, Efron DT. J Trauma Acute Care Surgery. 2018 Jul;85(1):160-166.
Limited data exists regarding the contemporary trends in the incidence and outcomes of penetrating trauma, although there has been a recent surge of national interest in the prevention of penetrating injuries and firearm violence. To optimize treatment of patients sustaining penetrating injuries, analysis of both pre-hospital and in-hospital mortality is vital in order to identify targeted areas to improve both the care of these patients and allocation of resources.
This study from Sakran and Mehta, et al, utilized the National Trauma Data Bank (NTDB) to analyze national trends in penetrating trauma and mortality. From 2007-2014, 437,398 patients were identified who sustained either stab (SW) or gunshot (GSW) wounds. These were divided into early and late time periods as defined by 2007-2010 (early) and 2010-2014 (late). Approximately half were GSWs. The authors evaluated pre-hospital mortality as defined by dead-on-arrival (DOA) or with no signs of life (lack of organized EKG activity, pupillary responses, spontaneous respirations or movement, or unassisted blood pressure) and in-house mortality.
The vast majority of deaths from penetrating trauma were due to GSWs (88.0%). While overall mortality was similar at 15.4% and 13.9% for GSWs in the early and late time periods, risk-adjusted pre-hospital mortality increased over time while in-house mortality decreased. Odds of pre-hospital death after GSW increased up to 4x in the past decade. If presenting to hospitals alive, patients sustaining injuries due to firearms had a significant decrease in mortality, including death in the ED. The authors attempted to evaluate the intensity of trauma deaths to determine if this factor was the etiology for the increase in pre-hospital mortality, evaluating the number of wounds, body location of injury, and number of body parts injured.
The findings presented in this study echo concerns concluded by many recent studies around the worsening epidemic of penetrating injury and firearm violence. While this study is retrospective and uses the NTDB which lacks granular data regarding pre-hospital time and interventions, it identifies the need for a multifactorial approach to violence prevention, pre-hospital resources, and timely access to trauma centers.
Article 3
School shootings during 2013-2015 in the USA. Kalesan B, Lagast K, Villarreal M, Pino E, Fagan J, Galea S. Inj Prev. 2017 Oct; 23(5): 321-327.
School shootings in the United States (US) continue to increase and surpass other countries across the globe. As the epidemic continues to worsen, the debate on gun control only grows stronger. Unfortunately, scientific data on the factors associated with these shootings are severely limited. This study aims to explore the relationship between state gun laws, mental health expenditure (MHE), childhood education and geographic location with school shootings.
The authors attempted to identify all school shootings in the US between January 2013 and December 2015 by querying LexisNexis Academic. Data collected on each incident included shooter characteristics, school characteristics, deaths and injuries. They then extracted information on background checks (BC) to purchase guns and ammunition, MHE, K-12 expenditure (KEE), and urbanicity for each state by querying various National Databanks. The authors created a negative binomial regression model (NBRM) to assess the relationship of school shootings with BC, MHE, KEE and urbanicity.
There were 154 documented school shootings during 2013-2015. Most events occurred in K-12 schools (54.6%), in metro areas (75.9%), were intentional shootings (66.2%) and performed by males (99.3%). In a NBRM, BC for firearm purchase (IRR=0.55, 95% CI 0.39-0.76, p<0.0001), BC for ammunition purchase (IRR=0.11, 95% CI 0.05-0.27, p<0.0001), log per capita MHE (IRR=0.58, 95% CI 0.37-0.90, p=0.016), KEE (IRR=0.09, 95% CI 0.02-0.29, p<0.0001) and urbanicity (IRR=0.97, 95% CI 0.96-0.99, p=0.002) were all found to be negatively associated with school shootings.
The results of this study demonstrate that school shootings may be negatively associated with existing BC gun laws and other state-level factors such as MHE and KEE. However there are several limitations to this study and one must interpret the data cautiously. First, the data comes from LexisNexis Academic, which is mostly composed of newspaper and media sources. This data is highly variable and the authors acknowledge a large amount of missing data and the inability to confirm reported data documented from media sources. Second, there is no clear way to identify if the authors captured all of the shootings during this time frame as they only captured shootings that were in the media, giving them a likely selection bias to more severe shootings. Finally, their ability to assess relationships between BC, MHE, KEE and urbanicity to school shootings is based solely on a modeling exercise and they acknowledge that this must be interpreted with caution. Overall, the authors do conclude that this paper demonstrates a need for a national surveillance registry of mass/school shootings with retrospective and prospective information so that objective data can be used to target specific items contributing to these unfortunate shootings. By having a registry and objective data, scientific methods can assist in changing public policy.
Article 4
The burden of firearm violence in the United States: stricter laws result in safer states. Jehan F, Pandit V, O’Keeffe T, Azim A, Jain A, Tai SA, Tang A, Khan M, Kulvatunyou N, Gries L, Joseph B. J Inj Violence Res. 2018 Jan; 10(1): 11-16.
Gun control legislation continues to be a main topic of debate in the United States. Since the passing of the second amendment in 1791, which protects the rights of individuals to keep and bear firearms, there has been a lack of federal legislation to pass stricter firearm laws. Statewide legislation for stricter gun control varies tremendously. The Brady scorecard can be used to numerically characterize states with strict versus non-strict gun laws. This study aims to determine the association between the rigorousness of firearm laws across different states and the rate of firearm related injuries and mortality.
The study uses the National Inpatient Sample (NIS) to identify all patients in 2011 admitted to a hospital with firearm related injuries, including suicides, suicide attempts, assaults and unintentional injuries. Data collected include demographics, mechanism of injury, length of stay, and in-hospital mortality. The authors use the Brady scoring method for all 50 states to calculate the strictness of each state’s gun control laws. The states were found to have a bimodal distribution and were divided into states with Strict Firearm Laws (SFL) and non-Strict Firearm Laws (non-SFL). Primary outcome was incidence of firearm related injuries and a Pearson correlation analysis was performed to assess the correlation between Brady score and rate of firearm related injuries. A linear regression analysis was also performed to evaluate the impact of firearm laws on firearm related injuries.
The authors identified 2,583 patients admitted to hospitals in 2011 for firearm injuries. Of these, 810 were from SFL states and 1,773 were from non-SFL states. In-hospital mortality was significantly lower in SFL states (8.3%) vs. non-SFL states (12.2%), p=0.002. Mechanism of injury was less likely due to suicide (13.7% vs. 27.7%) or unintentional event (17.8% vs. 32.3%) and more likely to be due to assault (68.8% vs. 40.2%) if the injury occurred in a SFL state vs. a non-SFL state (p<0.001). On Pearson’s correlation, the rate of firearm related injuries was found to negatively correlate with Brady score (R2 linear = -0.07, p=0.04) and had a correlation coefficient of -0.265. Linear regression analysis found that being in a SFL state decreased the mean rate of firearm related injury by 28% (Beta coefficient -0.28 (-1.7- -0.06) p=0.04)
This study, similar to previous ones, found a decrease in overall firearm related injuries in states with stricter firearm legislation. Specifically, there appears to be a decrease in suicide and unintentional firearm injuries in SFL states. Although this study does not prove direct causality, it does provide an overview of how stricter gun laws can impact society. However, caution must be taken in interpreting the data as this study relies on the NIS database, which only includes those admitted to a hospital. It does not include patients that die before reaching a hospital, a selection bias that has to be considered when interpreting this data.
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