Steven A. Sumner

Violence in the United States: Status, Challenges, and Opportunities

IMPORTANCE Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence. OBJECTIVES To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities. DATA SOURCES We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigations Uniform Crime Reports, the US Justice Departments National Crime Victimization Survey, the National Survey of Childrens Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System-All Injury Program. RESULTS Homicide rates have decreased from a peak of 10.7 per 100,000 persons in 1980 to 5.1 per 100,000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100,000 in 1992 to 242 per 100,000 in 2012. Nevertheless, annually, there are more than 16,000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.

Use of Naloxone by Emergency Medical Services during Opioid Drug Overdose Resuscitation Efforts

Abstract Naloxone administration is an important component of resuscitation attempts by emergency medical services (EMS) for opioid drug overdoses. However, EMS providers must first recognize the possibility of opioid overdose in clinical encounters. As part of a public health response to an outbreak of opioid overdoses in Rhode Island, we examined missed opportunities for naloxone administration and factors potentially influencing EMS providers’ decision to administer naloxone. We reviewed medical examiner files on all individuals who died of an opioid-related drug overdose in Rhode Island from January 1, 2012 through March 31, 2014, underwent attempted resuscitation by EMS providers, and had records available to assess for naloxone administration. We evaluated whether these individuals received naloxone as part of their resuscitation efforts and compared patient and scene characteristics of those who received naloxone to those who did not receive naloxone via chi-square, t-test, and logistic regression analyses. One hundred and twenty-four individuals who underwent attempted EMS resuscitation died due to opioid overdose. Naloxone was administered during EMS resuscitation attempts in 82 (66.1%) of cases. Females were nearly three-fold as likely not to receive naloxone as males (OR 2.9; 95% CI 1.2–7.0; p-value 0.02). Additionally, patients without signs of potential drug abuse also had a greater than three-fold odds of not receiving naloxone (OR 3.3; 95% CI 1.2–9.2; p-value 0.02). Older individuals, particularly those over age 50, were more likely not to receive naloxone than victims younger than age 30 (OR 4.8; 95% CI 1.3–17.4; p-value 0.02). Women, older individuals, and those patients without clear signs of illicit drug abuse, were less likely to receive naloxone in EMS resuscitation attempts. Heightened clinical suspicion for opioid overdose is important given the recent increase in overdoses among patients due to prescription opioids.

Policing and Public Health—Strategies for Collaboration

Policing and public health have largely been perceived by clinicians, researchers, and policy makers as 2 entirely separate approaches to reducing violence. This long-standing tradition, reinforced by the different languages of criminal justice systems (eg, deterrence, culpability, victimhood, and offending) and public health systems (eg, injury, risk factors, and epidemiology), has perhaps contributed to limited collaboration between local law enforcement agencies and public health to prevent violence. It has also probably limited collaboration between criminologists and population health researchers relative to other cross-discipline areas such as road traffic safety, prisoner health, and prevention of substance abuse.

Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk

Firearm violence has been identified by health and legal professionals as a critical public health problem (1). Homicide is the third leading cause of death in the United States among youth aged 15 to 24 years, with more than 86% of these deaths due to firearms (2). Furthermore, firearm violence results in substantial monetary cost; for example, medical and work-loss costs of nonfatal firearm injuries treated in U.S. emergency departments were estimated to exceed

Violence Against Children Surveys (VACS): towards a global surveillance system

2.9 billion in 2010 (3). Mitigating this public health issue requires novel hospital and community-based interventions that are focused on at-risk youth, especially those in urban communities. Urban emergency departments (EDs) have been identified as a critical access point for identifying and intervening with such youth (4). Firearm violence encompasses interpersonal, self-directed, and unintentional firearm-related incidents, but in this study we focus on interpersonal firearm violence, which we refer to simply as firearm violence throughout. Although previous ED-based research (5) has identified risk factors associated with firearm violence involvement among high-risk youth, the field of hospital and ED-based youth violence prevention programs lacks a short, clinically relevant screening tool that can be applied as part of routine clinical care in urban settings. Such a tool could play a key role in determining where to focus prevention or intervention efforts. Youth identified during an ED visit, particularly violently injured youth, are at elevated risk for future firearm violence (5) and thus would benefit most from early intervention, including case management and therapeutic services. Previous screening tools for youth violence (68) primarily focused on primary care settings, lack a specific focus on firearm violence, or are too lengthy for practical use in a busy ED setting. Furthermore, research on the construction of violence screening tools (6, 8) has been limited by small sample sizes and has not considered out-of-sample predictive power in devising the screen. Developing an ED/hospital-based clinical screening tool that is focused on assessing risk for future firearm violence will enable ED and hospital health systems to better focus prevention resources on patients at the highest risk. In the current study, we seek to develop a clinical screening tool for future risk for firearm violence by examining data collected as part of a 2-year prospective study of youth aged 14 to 24 years seeking ED care. First, we used machine learning methods to determine which variables measured at the baseline of a 2-year longitudinal study were most predictive of future firearm violence. Second, on the basis of breadth and clinical feasibility, we selected 4 items from among the most predictive variables. Third, we developed cut-points and assigned point values to each level based on their relative effects, resulting in the SaFETy (Serious fighting, Friend weapon carrying, community Environment, and firearm Threats) score. Finally, we examined the relationship between the SaFETy score and rates of future firearm violence within training and internal validation data sets. Methods Study Design and Setting Data were collected during the Flint Youth Injury study (911), a 2-year prospective cohort study of assault-injured youth (age 14 to 24 years) with any drug use in the past 6 months and a comparison group of nonassault-injured, drug-using youth seeking ED care at a level 1 trauma center in Flint, Michigan. The parent study focused on service needs and utilization among substance (predominantly marijuana) users. Although this potentially limits generalizability, we note that most youth who seek care for assault injuries in this setting are substance users (9). Patients were recruited from December 2009 through September 2011, 24 hours per day on Thursday through Monday and from 5 a.m. to 2 a.m. on Tuesday and Wednesday. Youth who sought care for sexual assault, child abuse, suicidal ideation or attempt, or any conditions that preclude consent (such as altered mental status) were excluded. Institutional review boards at the University of Michigan and Hurley Medical Center approved the study. A National Institutes of Health (NIH) Certificate of Confidentiality (COC) was obtained. Potential participants were ascertained through electronic patient logs and approached by research assistants in waiting or treatment areas. All assault-injured youth, including those who were initially unstable but stabilized with 72 hours of presentation, were approached and screened for study eligibility. In sequence, the next available age group (14 to 17, 18 to 20, and 21 to 24 years) and sex-matched, nonassault-injured ED entrant was screened for the comparison group. Those providing consent (or assent with parental consent for those younger than age 18 years) privately self-administered the screening survey using a tablet device and received a

Childhood sexual violence against boys: A study in 3 countries

1.00 gift for participation. Individuals who self-reported drug use in the past 6 months (98% used marijuana) were considered eligible and consented to the subsequent 2-year longitudinal study. Appendix Figure 1 shows a flow chart of the original study. Remuneration was

Disclosure of Sexual Violence Among Girls and Young Women Aged 13 to 24 Years: Results From the Violence Against Children Surveys in Nigeria and Malawi:

20 for completion of a subsequent self-administered baseline survey. Follow-up assessments were conducted at 6, 12, 18, and 24 months, and participants were compensated

Ability of crime, demographic and business data to forecast areas of increased violence

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Health system and law enforcement synergies for injury surveillance, control and prevention: a scoping review

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Sentinel Events Preceding Youth Firearm Violence: An Investigation of Administrative Data in Delaware.

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