- Email: [email protected]
Firearm violence in the United States: an overview1
antibodies induced a humoral and cellular immune response against a colorectal carcinoma-associated antigen in patients. Proc Natl Acad Sci U S A 1995;92: 4773– 4777. 7. Fearon ER, Pardoll DM, Itaya T, et al. Interleukin-2 production by tumor cells
bypasses T helper function in the generation of an antitumor response. Cell 1990;60:397– 403. 8. McLaughlin JP, Abrams S, Kantor J, et al. Immunization with a syngeneic tumor
infected with recombinant vaccinia virus expressing granulocyte-macrophage colony-stimulating factor (GM-CSF) induces tumor regression and long-lasting systemic immunity. J Immunother 1997;20:449 – 459. 9. Kantor J, Abrams S, Irvine K, et al. Specific immunotherapy using a recombinant
vaccinia virus expressing human carcinoembryonic antigen. Ann N Y Acad Sci 1993;690:370 –373. 10. Hodge JW, McLaughlin JP, Kantor JA, Schlom J. Diversified prime and boost
protocols using recombinant vaccinia virus and recombinant non-replicating avian pox virus to enhance T-cell immunity and antitumor responses. Vaccine 1997;15:759 –768. 11. Fries LF, Tartaglia J, Taylor J, et al. Human safety and immunogenicity of a
canarypox-rabies glycoprotein recombinant vaccine: an alternative poxvirus vector system. Vaccine 1996;14:428 – 434. 12. Rosenberg SA, Lotze MT, Yang JC, et al. Experience with the use of high-dose
interleukin-2 in the treatment of 652 cancer patients. Ann Surg 1989;210:474 – 485. 13. Lafreniere R, Rosenberg SA. Successful immunotherapy of murine experimental
hepatic metastases with lymphokine-activated killer cells and recombinant interleukin 2. Cancer Res 1985;45:3735–3741.
Trauma Firearm Violence in the United States: An Overview Guest Reviewers: Daniel G. Davis, DO, and James E. Barone, MD REVIEWER COMMENTS
THE MEDICAL COSTS OF GUNSHOT INJURIES IN THE UNITED STATES.
This study demonstrated the huge financial costs incurred in the treatment of victims of firearms-related injuries in the United States each year. The study is the first nationally representative estimate for the sources of payment for medical costs that are specific to gunshot injuries. Other studies have looked at individual states and the impact firearm violence has had. The sample size in this study is more than twice the size of those in previous studies looking at gunshot injuries, and
Cook PJ, Lawrence BA, Jens L, Miller TR. JAMA 1999;282:447– 454.
32
Objective: To develop reliable estimates of the medical costs of treating gunshot injuries in the United States and to present national estimates for the sources of payment for treating these injuries. Design: Cost analysis of discharge data from hospitals and national data base sources. Setting: Sanford Institute of Public Policy, Duke University, Durham, North Caro-
lina; National Public Services Research Institute, Landover, Maryland; and Georgetown Public Policy Institute, Georgetown University, Washington, District of Columbia. Participants: Hospitals in Maryland, South Carolina, and New York; data from the
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
National Electronic Injury Surveillance System, the National Spinal Cord Injury Statistical Center, and the 1994 Vital Statistics census. Methods: Estimated national acute care and follow-up treatment costs and payment
sources for 134,445 gunshot injuries in the United States in 1994. Results: At a mean medical cost per injury of about $17,000, the 134,445 (95%
confidence interval [CI], 109,465 to 159,425) gunshot injuries in the United States in 1994 produced $2.3 billion (95% CI, $2.1 billion to $2.5 billion) in lifetime medical costs (in 1994 dollars, using a 3% real discount rate), of which $1.1 billion (48%) was paid by United States taxpayers. Gunshot injuries due to assaults accounted for 74% of total costs. Conclusions: The authors concluded that gunshot injuries costs represent a substan-
tial burden to the medical care system. Nearly half this cost is borne by the taxpayers of the United States.
REVIEWER COMMENTS (Con’t)
the study also included a sample of cases treated in the emergency department. A study such as this consists of compiling data sets and making assumptions to arrive at estimates that may not be perfect. However, with the available information from such networks as the National Electronic Injury Surveillance System, the National Spinal Cord Injury Statistical Center (NSCISC), and the Vital Statistics data base, the ability to estimate the impact of gunshot injuries in the United States has improved. The authors admit that one of the limitations of the study was that their estimated costs for hospital treatment came from data from only 2 states, as no other states require hospitals to code for injury-related discharges and provide information that can identify actual medical costs. Another possible confounding factor in the study was that cost data were provided by one state and the data from the other state were based on charges. Another important limitation was the estimate of lifetime medical costs. This was based on one form of injury, spinal cord injury, for which the NSCISC data base provided information. Other types of injuries were based on dated information that did not distinguish between gunshot injuries and other injuries within the same International Classification of Diseases (ninth revision) diagnosis code. Despite its inherent limitations, the study points out that gunshot injuries result in huge financial costs and that improved surveillance and cost data are necessary if these estimates are to be improved.
MORTALITY AMONG RECENT PURCHASERS OF HANDGUNS. Wintemute
REVIEWER COMMENTS
GJ, Parham CA, Beaumont JJ, Wright M, Drake C. N Engl J Med 1999;341:1583–
This study highlights one of the growing controversies over handgun ownership and the risks of violent death. The authors studied the risks in relation to recent handgun purchases. They found that purchasers of handguns are at an increased risk for suicide, especially immediately after purchase. There was a near absence of suicides by firearm during the waiting period, which for this study was 15 days, followed by a marked increase in suicides the first month. Women were especially at risk during this period.
1589. Objective: To study the risk of death among persons who have recently purchased a
handgun. Design: Population-based cohort study. Setting: Violence Prevention Research Program, University of California, Davis, California. Participants: Persons (N ⫽ 238,292) who purchased handguns in California in
1991. Methods: The authors conducted a population-based cohort study to compare mor-
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
33
REVIEWER COMMENTS (Con’t)
Women were also at greater risk for death by homicide committed by an intimate partner with a firearm than for that committed by a stranger. They also found that the risk of death from homicide was lower among male purchasers of handguns than among men in the general population. This finding conflicts with previous studies, probably because of differences in the study populations. The current study included only those who legally purchased handguns, had passed a background check, and had no potential risk factors for violence. The expense of legally purchasing a handgun possibly places the study group into a higher socioeconomic group and would not represent the population as a whole, and therefore the homicide rate may not necessarily be the same in the general population. Another limitation with the study population is that it consists of only one state and its firearm regulations. States such as New York and New Jersey have very long waiting periods for handgun purchases, and the rate of suicide in this study may not be as high in these states. Also, there are many states that do not have strong laws regarding handgun purchasing among persons with previous history of violence, and therefore the rate of violent death may be higher in these states than in those in the study group. The study also did not look at the potential risk factors for suicidal behavior in the study group. The findings do not demonstrate that the purchase of a handgun caused suicidal behavior. It is known that the most common cause of firearmrelated deaths in the United States is suicide. The debate over handgun ownership and the laws regulating purchasing will continue. Thoroughly investigating the risk factors such as a history of violence, drug or alcohol abuse, and mental illness is imperative prior to the purchase of a handgun.
34
tality among the persons who purchased handguns in California with the general adult population in that state from 1991 through 1996. The standardized mortality ratio (the ratio of the number of deaths observed among handgun purchasers to the number expected on the basis of age- and sex-specific rates among adults in California) was the principal outcome measure. Results: In the first year after the purchase of a handgun, suicide was the leading
cause of death among handgun purchasers, accounting for 24.5% of all deaths and 51.9% of deaths among women 21 to 44 years old. The increased risk of suicide by any method among handgun purchasers (standardized mortality ratio ⫽ 4.31) was attributable entirely to an excess risk of suicide with a firearm (standardized mortality ratio ⫽ 7.12). In the first week after the purchase of a handgun, the rate of suicide by means of firearms among purchasers (644/100,000 person years) was 57 times as high as the adjusted rate in the general population. Mortality from all causes during the first year after the purchase of a handgun was greater than expected for women (standardized mortality ratio ⫽ 1.09), and the entire increase was attributable to the excess number of suicides by means of a firearm. As compared with the general population, handgun purchasers remained at increased risk for suicide by firearm over the study period of up to 6 years, and the excess risk among women in this cohort (standardized mortality ratio ⫽ 15.50) remained greater than that among men (standardized mortality ratio ⫽ 3.23). The risk of death by homicide with a firearm was elevated among women (standardized mortality ratio at 1 year ⫽ 2.20, standardized mortality ratio at 6 years ⫽ 2.01) but low among men (standardized mortality ratio at 1 year ⫽ 0.84, standardized mortality ratio at 6 years ⫽ 0.79). Conclusions: The purchase of a handgun is associated with a substantial increase in the risk of suicide by firearm and by any method. The increase in the risk of suicide by firearm is apparent within a week after the purchase of a handgun and persists for at least 6 years.
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
PRIOR MISDEMEANOR CONVICTIONS AS A RISK FACTOR FOR LATER VIOLENT AND FIREARM-RELATED CRIMINAL ACTIVITY AMONG AUTHORIZED PURCHASERS OF HANDGUNS. Wintemute GJ, Drake CM, Beaumont JJ, Wright MA, Parham CA. JAMA 1998;280:2083–2087. Objective: To determine whether authorized handgun purchasers with prior misdemeanor convictions are more likely than those with no criminal history to be charged with new crimes, particularly offenses involving firearms and violence. Design: Retrospective cohort study. Setting: Violence Prevention Research Program, University of California, Davis, California. Participants: A total of 5923 authorized purchasers of handguns in California in
1977 who were younger than 50 years, identified by random sample. Methods: The study population was identified by random sampling from a com-
puterized registry of all persons who purchased a handgun in 1977. Entries were stratified by a notation that indicated that the purchaser had a record on file with the Department of Justice and may have had a criminal history. The main outcome was the incidence and relative risk of first charges for new criminal offenses after handgun purchases. Results: Of the 5923 authorized purchasers, 3128 had at least 1 conviction for a
misdemeanor offense before handgun purchase, and 2795 had no prior criminal history. Follow-up to the end of the 15-year observation period or to death was available for 77.8% of study subjects and for a median of 8.9 years for another 9.6%. Handgun purchasers with at least 1 prior misdemeanor conviction were more than 7 times as likely as those with no prior criminal history to be charged with a new offense after handgun purchase (relative risk [RR], 7.5; 95% confidence interval [CI], 6.6 to 8.7). Men with 2 or more prior convictions for misdemeanor violence were at greatest risk for nonviolent firearm-related offenses such as weapon carrying (RR, 11.7; 95% CI, 6.8 to 20.0), violent offenses generally (RR, 10.4; 95% CI, 6.9 to 15.8), and Violent Crime Index offenses (murder or nonnegligent manslaughter, forcible rape, robbery, or aggravated assault; RR, 15.1; 95% CI, 9.4 to 24.3). Conclusions: Handgun purchasers with prior misdemeanor convictions are at
increased risk for future criminal activity, including violent and firearm-related crimes.
REVIEWER COMMENTS
Evidence continues to mount against handgun purchasing by persons at high risk for violence. The study by the Violence Prevention Research Program at University of California, Davis has found evidence that prior misdemeanor convictions are another risk factor for future criminal activity after handgun purchase. The study included 3128 handgun purchasers with at least 1 misdemeanor conviction and 2795 handgun purchasers with no history of convictions. The striking finding that the group with history of 1 conviction is 7 times as likely to commit a future criminal activity is probably conservative. The authors state that handgun purchasers with prior misdemeanor convictions in other states would have been classified by the study as having no prior criminal history if the convictions did not appear on the California criminal record. The findings are even more impressive when the history of criminal activity increases. Persons with more than 1 offense are 10 times as likely to be charged with new criminal activity and 15 times as likely to be charged with murder, rape, robbery, or aggravated assault. Even though the risk of new violent offenses is nothing new for those who have a history of violent crimes, the authors show evidence that commission of nonviolent crimes is also a risk factor. The current federal law does not include misdemeanor crimes (with the exception of crimes of domestic violence) as a factor to prohibit handgun sale. The study provides evidence that even misdemeanors should be included in the federal law criteria for prohibiting handgun sale.
SUPPORT FOR NEW POLICIES TO REGULATE FIREARMS. Teret SP, Webster
REVIEWER COMMENTS
DW, Vernick JS, et al. N Engl J Med 1998;339:813– 818.
The firearm policy in the United States is under considerable debate now more than ever. Regulation of firearms is a hot topic that raises controversy from both sides of the issue. Supporters of handgun ownership cite the Second Amendment
Objective: To assess public opinion on new gun policy options. Design: Two telephone surveys that focused on innovative gun-related policies. Setting: Johns Hopkins Center for Gun Policy and Research, Johns Hopkins School of Public Health, Baltimore, Maryland.
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
35
REVIEWER COMMENTS (Con’t)
Participants: Twelve hundred adults in the United States.
to the United States Constitution as confirming their right to bear arms. Gun control proponents cite the ready availability of handguns and injuries and deaths caused by them. New policy options have been proposed to attempt to achieve a reasonable agreement between the 2 groups and to treat and regulate handguns as consumer products. The authors conducted a study to assess public opinion on the innovative gun policy options. The findings will be utilized by gun control supporters, but one must realize that the survey involved only 2400 people. The study suggests that the majority of those questioned, and even the majority of handgun owners, favor treating handguns as consumer products. Stronger safety standards would make firearms less dangerous and still allow the right to own a firearm. The study gives some support to those who feel that the federal government needs to act now to control this problem and offers somewhat of a compromise that stops short of a complete ban on handguns. Opponents of gun control would argue that devices such as gun and personalization locks have never been shown to be effective.
Methods: Two telephone surveys of 1200 adults each in the United States were
conducted in 1996 and 1997–1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit telephone number dialing. Results: A majority of the respondents favored safety standards for new handguns.
These standards included childproofing (favored by 88% of respondents), personalization (devices that permit firing only by an authorized person; 71%), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82%), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73%). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83% to 95%) or substance abuse (71% to 92%). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90%), a limit of 1 handgun purchase per customer per month (81%), and mandatory registration of handguns (82%). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll. Conclusions: Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policymakers.
REVIEWER SUMMARY An estimated 1.2 million firearm-related violent crimes occurred in the United States in 1995, more than 80% of which involved handguns.1–3 The United States leads the world in deaths by firearms, with more than 30,000 deaths each year as reported by the Centers for Disease Control and Prevention. Injuries from firearms are the second leading cause of death for Americans 15 to 24 years of age, and the number of nonfatal firearm injuries is estimated at over 80,000 annually.4 The abstracts presented in this overview of firearm violence reveal the epidemic proportions that we as a nation face. Each article chosen for review highlighted the concerns over firearms in the United States. The study by Cook and colleagues estimated the lifetime medical costs of gunshot injuries at $2.3 billion and cost to the taxpayers at least $1.1 billion. The victims are theoretically responsible for the remaining costs. Another study found that the victims are nearly 6 times more likely to become bad debts and ultimately be covered by other sources.5 The enormous cost has prompted legal actions against the gun industry by some cities in the United States. The outcomes of these suits are yet to be determined. Handgun ownership has also been linked to the increased risk of suicides and homicides.6 – 8 It is estimated that guns are used in 62% of suicide attempts among men and 39.3% among women, with death in approximately 85% of cases. Guns were used in 41% of the homicides. The data from these studies were geographically limited and 36
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
only 1 study related the risk of death to handgun ownership.7 The study by Wintemute and colleagues published in 1999 found the risk of suicide to be greater among new purchasers of handguns, especially during the first week, and to persist for at least 6 years. More women are victims of homicide, which is often committed by an intimate partner. The authors were unable to determine whether the handguns that were actually purchased were involved in the deaths, but there was definitely a greater risk of death among recent handgun purchasers. The risk factors associated with firearm violence have also been shown to be a major contributing cause of the increase in deaths. Laws prohibit the purchase of guns by persons at high risk for violence. According to the Gun Control Act of 1968, persons with prior felony convictions, fugitives from justice, persons adjudicated to be mentally ill, and persons found guilty of misdemeanors involving domestic violence are prohibited from firearm purchase. The study by Wintemute and colleagues published in 1998 provides evidence that persons with prior misdemeanors are at increased risk for future criminal activity, including violent and firearm-related crimes. The study supports new policies for handgun regulation, including prohibiting all persons convicted of a crime from ever purchasing a gun. Encouraging news comes from the Centers for Disease Control and Prevention, which have shown that firearm-related injuries and deaths are declining in the United States but still remain high.4 Physicians have emphasized that firearm violence is a public health epidemic. The Violence Prevention Task Force formed by the Eastern Association for the Surgery of Trauma looked at firearm violence and made recommendations that are intended to reduce firearm-related injury and death. The policies recommended have been endorsed by other large physician groups, and prevention has been the goal. Innovative policies to aid in firearm violence prevention have been presented. Teret and colleagues’ study determined that there was strong public support, even among gun owners, for innovative strategies to regulate firearms. Firearms need to be regulated as a consumer product and subject to the same safety and design criteria as other products. Identifying and prohibiting sales of guns to persons with risk factors and innovative policies for handgun regulation may help decrease firearm violence.
DANIEL G. DAVIS, DO JAMES E. BARONE, MD Department of Surgery The Stamford Hospital Stamford, Connecticut PII S0149-7944(00)00150-1
REFERENCES 1. Taylor BM. Changes in criminal victimization, 1994 –1995 (NCJ Publication No.
162032). Washington, DC: Bureau of Justice Statistics, 1997. 2. Crime in the United States, 1995. Washington, DC: Federal Bureau of Investiga-
tion, 1996. 3. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal
firearm-related injuries: beyond the tip of the iceberg. JAMA 1995;273:1749 – 1754. 4. Cherry D, Annest JL, Mercy JA, Kresnow M, Pollock DA. Trends in nonfatal and
fatal firearm-related injury rates in the United States, 1985–1995. Ann Emerg Med 1998;32:51–59. 5. Weissman JS, Lukas CVD, Epstein AM. Bad debt and free care in Massachusetts
hospitals. Health Aff (Millwood) 1992;11:148 –161. CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
37
6. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun
ownership. N Engl J Med 1992;327:467– 472. 7. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. The
association between the purchase of a handgun and homicide or suicide. Am J Public Health 1997;87:974 –978. 8. Bailey JE, Kellermann AL, Somes GW, et al. Risk factors for violent death of
women in the home. Arch Intern Med 1997;157:777–782.
Trauma Spinal Cord Injury: Are There Grounds for New Hope? Guest Reviewer: Michael H. Metzler, MD REVIEWER COMMENTS
This article emphasizes aggressive use of invasive monitoring, volume loading, and use of pressors to maintain MAP above an arbitrary value of 85 mm Hg for 7 days postinjury (this value extrapolated from treatment data of cerebral perfusion pressure in brain injury studies designed to prevent secondary brain injury). Forty to 90% of patients required pressors, depending on whether they had incomplete or complete ASIA grade injuries. It is not clear how the Swan–Ganz catheter was used, except as a method of preload determination. It may have been possible to do this with central venous pressure monitoring. The outcomes are rather spectacular.
COMBINED MEDICAL AND SURGICAL TREATMENT AFTER ACUTE SPINAL CORD INJURY: RESULTS OF A PROSPECTIVE PILOT STUDY TO ASSESS THE MERITS OF AGGRESSIVE MEDICAL RESUSCITATION AND BLOOD PRESSURE MEASUREMENT. Vale FL, Burns J, Jackson AB, Hadley MN. J Neurosurg 1997;87:239 –246. Objective: To determine if aggressive volume replacement and blood pressure man-
agement of spinal cord injury patients, coupled with selective surgical decompression and stabilization, improved outcome at 18 months postinjury. Design: Prospective treatment protocol for spinal trauma from 1992 to 1997; historic controls. Setting: University teaching hospital, Division of Neurosurgery and Department of
Rehabilitative Medicine, University of Alabama, Birmingham, Alabama. Participants: Seventy-seven patients with acute cervical (45) and thoracic (32) spi-
nal cord injuries. Methods: Initial neurologic examinationss were performed by 2 examiners. Swan–
Ganz and arterial catheters were inserted. Volume and vasopressors were used to keep mean arterial pressure (MAP) greater than 85 mm Hg for 7 days (unless MAP ⬎ 85 mm Hg could be maintained without pressors). All patients received methylprednisolone according to National Acute Spinal Cord Injury Study II guidelines for 24 hours. Early fracture-dislocation reduction and stabilization was performed if cord compression was noted on magnetic resonance imaging, and patient was thought medically stable. Full rehabilitation was begun on discharge from acute care. Detailed neurologic assessments were performed at 6, 12, and 18 months postinjury. Mean follow-up was 17 months; 64 patients were followed at least 12 months. All patients were graded by the American Spinal Injury Association (ASIA) as to completeness of neurologic function and motor index score. Results: At last follow-up, 60% of patients with initial complete cervical cord injury
had improved at least 1 ASIA grade over initial evaluation; 33% were able to walk, and 20% had bladder control. Thirty-three percent of complete thoracic cord injuries improved at least 1 ASIA grade; 10% could walk and had bladder control. Incomplete cervical lesion patients had a 92% clinical improvement rate: 92% regained ability to walk; 88% had bladder function. 38
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
bypasses T helper function in the generation of an antitumor response. Cell 1990;60:397– 403. 8. McLaughlin JP, Abrams S, Kantor J, et al. Immunization with a syngeneic tumor
infected with recombinant vaccinia virus expressing granulocyte-macrophage colony-stimulating factor (GM-CSF) induces tumor regression and long-lasting systemic immunity. J Immunother 1997;20:449 – 459. 9. Kantor J, Abrams S, Irvine K, et al. Specific immunotherapy using a recombinant
vaccinia virus expressing human carcinoembryonic antigen. Ann N Y Acad Sci 1993;690:370 –373. 10. Hodge JW, McLaughlin JP, Kantor JA, Schlom J. Diversified prime and boost
protocols using recombinant vaccinia virus and recombinant non-replicating avian pox virus to enhance T-cell immunity and antitumor responses. Vaccine 1997;15:759 –768. 11. Fries LF, Tartaglia J, Taylor J, et al. Human safety and immunogenicity of a
canarypox-rabies glycoprotein recombinant vaccine: an alternative poxvirus vector system. Vaccine 1996;14:428 – 434. 12. Rosenberg SA, Lotze MT, Yang JC, et al. Experience with the use of high-dose
interleukin-2 in the treatment of 652 cancer patients. Ann Surg 1989;210:474 – 485. 13. Lafreniere R, Rosenberg SA. Successful immunotherapy of murine experimental
hepatic metastases with lymphokine-activated killer cells and recombinant interleukin 2. Cancer Res 1985;45:3735–3741.
Trauma Firearm Violence in the United States: An Overview Guest Reviewers: Daniel G. Davis, DO, and James E. Barone, MD REVIEWER COMMENTS
THE MEDICAL COSTS OF GUNSHOT INJURIES IN THE UNITED STATES.
This study demonstrated the huge financial costs incurred in the treatment of victims of firearms-related injuries in the United States each year. The study is the first nationally representative estimate for the sources of payment for medical costs that are specific to gunshot injuries. Other studies have looked at individual states and the impact firearm violence has had. The sample size in this study is more than twice the size of those in previous studies looking at gunshot injuries, and
Cook PJ, Lawrence BA, Jens L, Miller TR. JAMA 1999;282:447– 454.
32
Objective: To develop reliable estimates of the medical costs of treating gunshot injuries in the United States and to present national estimates for the sources of payment for treating these injuries. Design: Cost analysis of discharge data from hospitals and national data base sources. Setting: Sanford Institute of Public Policy, Duke University, Durham, North Caro-
lina; National Public Services Research Institute, Landover, Maryland; and Georgetown Public Policy Institute, Georgetown University, Washington, District of Columbia. Participants: Hospitals in Maryland, South Carolina, and New York; data from the
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
National Electronic Injury Surveillance System, the National Spinal Cord Injury Statistical Center, and the 1994 Vital Statistics census. Methods: Estimated national acute care and follow-up treatment costs and payment
sources for 134,445 gunshot injuries in the United States in 1994. Results: At a mean medical cost per injury of about $17,000, the 134,445 (95%
confidence interval [CI], 109,465 to 159,425) gunshot injuries in the United States in 1994 produced $2.3 billion (95% CI, $2.1 billion to $2.5 billion) in lifetime medical costs (in 1994 dollars, using a 3% real discount rate), of which $1.1 billion (48%) was paid by United States taxpayers. Gunshot injuries due to assaults accounted for 74% of total costs. Conclusions: The authors concluded that gunshot injuries costs represent a substan-
tial burden to the medical care system. Nearly half this cost is borne by the taxpayers of the United States.
REVIEWER COMMENTS (Con’t)
the study also included a sample of cases treated in the emergency department. A study such as this consists of compiling data sets and making assumptions to arrive at estimates that may not be perfect. However, with the available information from such networks as the National Electronic Injury Surveillance System, the National Spinal Cord Injury Statistical Center (NSCISC), and the Vital Statistics data base, the ability to estimate the impact of gunshot injuries in the United States has improved. The authors admit that one of the limitations of the study was that their estimated costs for hospital treatment came from data from only 2 states, as no other states require hospitals to code for injury-related discharges and provide information that can identify actual medical costs. Another possible confounding factor in the study was that cost data were provided by one state and the data from the other state were based on charges. Another important limitation was the estimate of lifetime medical costs. This was based on one form of injury, spinal cord injury, for which the NSCISC data base provided information. Other types of injuries were based on dated information that did not distinguish between gunshot injuries and other injuries within the same International Classification of Diseases (ninth revision) diagnosis code. Despite its inherent limitations, the study points out that gunshot injuries result in huge financial costs and that improved surveillance and cost data are necessary if these estimates are to be improved.
MORTALITY AMONG RECENT PURCHASERS OF HANDGUNS. Wintemute
REVIEWER COMMENTS
GJ, Parham CA, Beaumont JJ, Wright M, Drake C. N Engl J Med 1999;341:1583–
This study highlights one of the growing controversies over handgun ownership and the risks of violent death. The authors studied the risks in relation to recent handgun purchases. They found that purchasers of handguns are at an increased risk for suicide, especially immediately after purchase. There was a near absence of suicides by firearm during the waiting period, which for this study was 15 days, followed by a marked increase in suicides the first month. Women were especially at risk during this period.
1589. Objective: To study the risk of death among persons who have recently purchased a
handgun. Design: Population-based cohort study. Setting: Violence Prevention Research Program, University of California, Davis, California. Participants: Persons (N ⫽ 238,292) who purchased handguns in California in
1991. Methods: The authors conducted a population-based cohort study to compare mor-
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
33
REVIEWER COMMENTS (Con’t)
Women were also at greater risk for death by homicide committed by an intimate partner with a firearm than for that committed by a stranger. They also found that the risk of death from homicide was lower among male purchasers of handguns than among men in the general population. This finding conflicts with previous studies, probably because of differences in the study populations. The current study included only those who legally purchased handguns, had passed a background check, and had no potential risk factors for violence. The expense of legally purchasing a handgun possibly places the study group into a higher socioeconomic group and would not represent the population as a whole, and therefore the homicide rate may not necessarily be the same in the general population. Another limitation with the study population is that it consists of only one state and its firearm regulations. States such as New York and New Jersey have very long waiting periods for handgun purchases, and the rate of suicide in this study may not be as high in these states. Also, there are many states that do not have strong laws regarding handgun purchasing among persons with previous history of violence, and therefore the rate of violent death may be higher in these states than in those in the study group. The study also did not look at the potential risk factors for suicidal behavior in the study group. The findings do not demonstrate that the purchase of a handgun caused suicidal behavior. It is known that the most common cause of firearmrelated deaths in the United States is suicide. The debate over handgun ownership and the laws regulating purchasing will continue. Thoroughly investigating the risk factors such as a history of violence, drug or alcohol abuse, and mental illness is imperative prior to the purchase of a handgun.
34
tality among the persons who purchased handguns in California with the general adult population in that state from 1991 through 1996. The standardized mortality ratio (the ratio of the number of deaths observed among handgun purchasers to the number expected on the basis of age- and sex-specific rates among adults in California) was the principal outcome measure. Results: In the first year after the purchase of a handgun, suicide was the leading
cause of death among handgun purchasers, accounting for 24.5% of all deaths and 51.9% of deaths among women 21 to 44 years old. The increased risk of suicide by any method among handgun purchasers (standardized mortality ratio ⫽ 4.31) was attributable entirely to an excess risk of suicide with a firearm (standardized mortality ratio ⫽ 7.12). In the first week after the purchase of a handgun, the rate of suicide by means of firearms among purchasers (644/100,000 person years) was 57 times as high as the adjusted rate in the general population. Mortality from all causes during the first year after the purchase of a handgun was greater than expected for women (standardized mortality ratio ⫽ 1.09), and the entire increase was attributable to the excess number of suicides by means of a firearm. As compared with the general population, handgun purchasers remained at increased risk for suicide by firearm over the study period of up to 6 years, and the excess risk among women in this cohort (standardized mortality ratio ⫽ 15.50) remained greater than that among men (standardized mortality ratio ⫽ 3.23). The risk of death by homicide with a firearm was elevated among women (standardized mortality ratio at 1 year ⫽ 2.20, standardized mortality ratio at 6 years ⫽ 2.01) but low among men (standardized mortality ratio at 1 year ⫽ 0.84, standardized mortality ratio at 6 years ⫽ 0.79). Conclusions: The purchase of a handgun is associated with a substantial increase in the risk of suicide by firearm and by any method. The increase in the risk of suicide by firearm is apparent within a week after the purchase of a handgun and persists for at least 6 years.
CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
PRIOR MISDEMEANOR CONVICTIONS AS A RISK FACTOR FOR LATER VIOLENT AND FIREARM-RELATED CRIMINAL ACTIVITY AMONG AUTHORIZED PURCHASERS OF HANDGUNS. Wintemute GJ, Drake CM, Beaumont JJ, Wright MA, Parham CA. JAMA 1998;280:2083–2087. Objective: To determine whether authorized handgun purchasers with prior misdemeanor convictions are more likely than those with no criminal history to be charged with new crimes, particularly offenses involving firearms and violence. Design: Retrospective cohort study. Setting: Violence Prevention Research Program, University of California, Davis, California. Participants: A total of 5923 authorized purchasers of handguns in California in
1977 who were younger than 50 years, identified by random sample. Methods: The study population was identified by random sampling from a com-
puterized registry of all persons who purchased a handgun in 1977. Entries were stratified by a notation that indicated that the purchaser had a record on file with the Department of Justice and may have had a criminal history. The main outcome was the incidence and relative risk of first charges for new criminal offenses after handgun purchases. Results: Of the 5923 authorized purchasers, 3128 had at least 1 conviction for a
misdemeanor offense before handgun purchase, and 2795 had no prior criminal history. Follow-up to the end of the 15-year observation period or to death was available for 77.8% of study subjects and for a median of 8.9 years for another 9.6%. Handgun purchasers with at least 1 prior misdemeanor conviction were more than 7 times as likely as those with no prior criminal history to be charged with a new offense after handgun purchase (relative risk [RR], 7.5; 95% confidence interval [CI], 6.6 to 8.7). Men with 2 or more prior convictions for misdemeanor violence were at greatest risk for nonviolent firearm-related offenses such as weapon carrying (RR, 11.7; 95% CI, 6.8 to 20.0), violent offenses generally (RR, 10.4; 95% CI, 6.9 to 15.8), and Violent Crime Index offenses (murder or nonnegligent manslaughter, forcible rape, robbery, or aggravated assault; RR, 15.1; 95% CI, 9.4 to 24.3). Conclusions: Handgun purchasers with prior misdemeanor convictions are at
increased risk for future criminal activity, including violent and firearm-related crimes.
REVIEWER COMMENTS
Evidence continues to mount against handgun purchasing by persons at high risk for violence. The study by the Violence Prevention Research Program at University of California, Davis has found evidence that prior misdemeanor convictions are another risk factor for future criminal activity after handgun purchase. The study included 3128 handgun purchasers with at least 1 misdemeanor conviction and 2795 handgun purchasers with no history of convictions. The striking finding that the group with history of 1 conviction is 7 times as likely to commit a future criminal activity is probably conservative. The authors state that handgun purchasers with prior misdemeanor convictions in other states would have been classified by the study as having no prior criminal history if the convictions did not appear on the California criminal record. The findings are even more impressive when the history of criminal activity increases. Persons with more than 1 offense are 10 times as likely to be charged with new criminal activity and 15 times as likely to be charged with murder, rape, robbery, or aggravated assault. Even though the risk of new violent offenses is nothing new for those who have a history of violent crimes, the authors show evidence that commission of nonviolent crimes is also a risk factor. The current federal law does not include misdemeanor crimes (with the exception of crimes of domestic violence) as a factor to prohibit handgun sale. The study provides evidence that even misdemeanors should be included in the federal law criteria for prohibiting handgun sale.
SUPPORT FOR NEW POLICIES TO REGULATE FIREARMS. Teret SP, Webster
REVIEWER COMMENTS
DW, Vernick JS, et al. N Engl J Med 1998;339:813– 818.
The firearm policy in the United States is under considerable debate now more than ever. Regulation of firearms is a hot topic that raises controversy from both sides of the issue. Supporters of handgun ownership cite the Second Amendment
Objective: To assess public opinion on new gun policy options. Design: Two telephone surveys that focused on innovative gun-related policies. Setting: Johns Hopkins Center for Gun Policy and Research, Johns Hopkins School of Public Health, Baltimore, Maryland.
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REVIEWER COMMENTS (Con’t)
Participants: Twelve hundred adults in the United States.
to the United States Constitution as confirming their right to bear arms. Gun control proponents cite the ready availability of handguns and injuries and deaths caused by them. New policy options have been proposed to attempt to achieve a reasonable agreement between the 2 groups and to treat and regulate handguns as consumer products. The authors conducted a study to assess public opinion on the innovative gun policy options. The findings will be utilized by gun control supporters, but one must realize that the survey involved only 2400 people. The study suggests that the majority of those questioned, and even the majority of handgun owners, favor treating handguns as consumer products. Stronger safety standards would make firearms less dangerous and still allow the right to own a firearm. The study gives some support to those who feel that the federal government needs to act now to control this problem and offers somewhat of a compromise that stops short of a complete ban on handguns. Opponents of gun control would argue that devices such as gun and personalization locks have never been shown to be effective.
Methods: Two telephone surveys of 1200 adults each in the United States were
conducted in 1996 and 1997–1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit telephone number dialing. Results: A majority of the respondents favored safety standards for new handguns.
These standards included childproofing (favored by 88% of respondents), personalization (devices that permit firing only by an authorized person; 71%), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82%), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73%). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83% to 95%) or substance abuse (71% to 92%). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90%), a limit of 1 handgun purchase per customer per month (81%), and mandatory registration of handguns (82%). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll. Conclusions: Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policymakers.
REVIEWER SUMMARY An estimated 1.2 million firearm-related violent crimes occurred in the United States in 1995, more than 80% of which involved handguns.1–3 The United States leads the world in deaths by firearms, with more than 30,000 deaths each year as reported by the Centers for Disease Control and Prevention. Injuries from firearms are the second leading cause of death for Americans 15 to 24 years of age, and the number of nonfatal firearm injuries is estimated at over 80,000 annually.4 The abstracts presented in this overview of firearm violence reveal the epidemic proportions that we as a nation face. Each article chosen for review highlighted the concerns over firearms in the United States. The study by Cook and colleagues estimated the lifetime medical costs of gunshot injuries at $2.3 billion and cost to the taxpayers at least $1.1 billion. The victims are theoretically responsible for the remaining costs. Another study found that the victims are nearly 6 times more likely to become bad debts and ultimately be covered by other sources.5 The enormous cost has prompted legal actions against the gun industry by some cities in the United States. The outcomes of these suits are yet to be determined. Handgun ownership has also been linked to the increased risk of suicides and homicides.6 – 8 It is estimated that guns are used in 62% of suicide attempts among men and 39.3% among women, with death in approximately 85% of cases. Guns were used in 41% of the homicides. The data from these studies were geographically limited and 36
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only 1 study related the risk of death to handgun ownership.7 The study by Wintemute and colleagues published in 1999 found the risk of suicide to be greater among new purchasers of handguns, especially during the first week, and to persist for at least 6 years. More women are victims of homicide, which is often committed by an intimate partner. The authors were unable to determine whether the handguns that were actually purchased were involved in the deaths, but there was definitely a greater risk of death among recent handgun purchasers. The risk factors associated with firearm violence have also been shown to be a major contributing cause of the increase in deaths. Laws prohibit the purchase of guns by persons at high risk for violence. According to the Gun Control Act of 1968, persons with prior felony convictions, fugitives from justice, persons adjudicated to be mentally ill, and persons found guilty of misdemeanors involving domestic violence are prohibited from firearm purchase. The study by Wintemute and colleagues published in 1998 provides evidence that persons with prior misdemeanors are at increased risk for future criminal activity, including violent and firearm-related crimes. The study supports new policies for handgun regulation, including prohibiting all persons convicted of a crime from ever purchasing a gun. Encouraging news comes from the Centers for Disease Control and Prevention, which have shown that firearm-related injuries and deaths are declining in the United States but still remain high.4 Physicians have emphasized that firearm violence is a public health epidemic. The Violence Prevention Task Force formed by the Eastern Association for the Surgery of Trauma looked at firearm violence and made recommendations that are intended to reduce firearm-related injury and death. The policies recommended have been endorsed by other large physician groups, and prevention has been the goal. Innovative policies to aid in firearm violence prevention have been presented. Teret and colleagues’ study determined that there was strong public support, even among gun owners, for innovative strategies to regulate firearms. Firearms need to be regulated as a consumer product and subject to the same safety and design criteria as other products. Identifying and prohibiting sales of guns to persons with risk factors and innovative policies for handgun regulation may help decrease firearm violence.
DANIEL G. DAVIS, DO JAMES E. BARONE, MD Department of Surgery The Stamford Hospital Stamford, Connecticut PII S0149-7944(00)00150-1
REFERENCES 1. Taylor BM. Changes in criminal victimization, 1994 –1995 (NCJ Publication No.
162032). Washington, DC: Bureau of Justice Statistics, 1997. 2. Crime in the United States, 1995. Washington, DC: Federal Bureau of Investiga-
tion, 1996. 3. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal
firearm-related injuries: beyond the tip of the iceberg. JAMA 1995;273:1749 – 1754. 4. Cherry D, Annest JL, Mercy JA, Kresnow M, Pollock DA. Trends in nonfatal and
fatal firearm-related injury rates in the United States, 1985–1995. Ann Emerg Med 1998;32:51–59. 5. Weissman JS, Lukas CVD, Epstein AM. Bad debt and free care in Massachusetts
hospitals. Health Aff (Millwood) 1992;11:148 –161. CURRENT SURGERY • Volume 57/Number 1 • January/February 2000
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6. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun
ownership. N Engl J Med 1992;327:467– 472. 7. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. The
association between the purchase of a handgun and homicide or suicide. Am J Public Health 1997;87:974 –978. 8. Bailey JE, Kellermann AL, Somes GW, et al. Risk factors for violent death of
women in the home. Arch Intern Med 1997;157:777–782.
Trauma Spinal Cord Injury: Are There Grounds for New Hope? Guest Reviewer: Michael H. Metzler, MD REVIEWER COMMENTS
This article emphasizes aggressive use of invasive monitoring, volume loading, and use of pressors to maintain MAP above an arbitrary value of 85 mm Hg for 7 days postinjury (this value extrapolated from treatment data of cerebral perfusion pressure in brain injury studies designed to prevent secondary brain injury). Forty to 90% of patients required pressors, depending on whether they had incomplete or complete ASIA grade injuries. It is not clear how the Swan–Ganz catheter was used, except as a method of preload determination. It may have been possible to do this with central venous pressure monitoring. The outcomes are rather spectacular.
COMBINED MEDICAL AND SURGICAL TREATMENT AFTER ACUTE SPINAL CORD INJURY: RESULTS OF A PROSPECTIVE PILOT STUDY TO ASSESS THE MERITS OF AGGRESSIVE MEDICAL RESUSCITATION AND BLOOD PRESSURE MEASUREMENT. Vale FL, Burns J, Jackson AB, Hadley MN. J Neurosurg 1997;87:239 –246. Objective: To determine if aggressive volume replacement and blood pressure man-
agement of spinal cord injury patients, coupled with selective surgical decompression and stabilization, improved outcome at 18 months postinjury. Design: Prospective treatment protocol for spinal trauma from 1992 to 1997; historic controls. Setting: University teaching hospital, Division of Neurosurgery and Department of
Rehabilitative Medicine, University of Alabama, Birmingham, Alabama. Participants: Seventy-seven patients with acute cervical (45) and thoracic (32) spi-
nal cord injuries. Methods: Initial neurologic examinationss were performed by 2 examiners. Swan–
Ganz and arterial catheters were inserted. Volume and vasopressors were used to keep mean arterial pressure (MAP) greater than 85 mm Hg for 7 days (unless MAP ⬎ 85 mm Hg could be maintained without pressors). All patients received methylprednisolone according to National Acute Spinal Cord Injury Study II guidelines for 24 hours. Early fracture-dislocation reduction and stabilization was performed if cord compression was noted on magnetic resonance imaging, and patient was thought medically stable. Full rehabilitation was begun on discharge from acute care. Detailed neurologic assessments were performed at 6, 12, and 18 months postinjury. Mean follow-up was 17 months; 64 patients were followed at least 12 months. All patients were graded by the American Spinal Injury Association (ASIA) as to completeness of neurologic function and motor index score. Results: At last follow-up, 60% of patients with initial complete cervical cord injury
had improved at least 1 ASIA grade over initial evaluation; 33% were able to walk, and 20% had bladder control. Thirty-three percent of complete thoracic cord injuries improved at least 1 ASIA grade; 10% could walk and had bladder control. Incomplete cervical lesion patients had a 92% clinical improvement rate: 92% regained ability to walk; 88% had bladder function. 38
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