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Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.


Carter PM, Walton MA, Roehler DR, et al. Firearm Violence Among High-Risk Emergency Department Youth After an Assault Injury. Pediatrics. 2015;135(5):805-815.

Comment: Lenworth Jacobs, MD, FACS

Firearm violence is a major problem in the United States; it is particularly prevalent in younger age groups. This study focuses on very real clinical and sociologic factors associated with the significant morbidity and mortality related to firearm violence. It has also identified a potential prevention strategy that could be implemented in the emergency department setting with relatively straightforward screening tools.

The authors selected an interesting age cohort—between 14 and 24. Clearly, 14-year-olds are identified as children, even though they may demonstrate adult behaviors; the post-high school group of 18 to 22 is old enough to work independently, can enroll in military service, and is generally thought to be made up of maturing young adults; by any definition, 22-to 24-year-olds are considered to be mature young adults.

This youngest-age cohort (14-year-olds) requires learning behavior strategies that are in the pediatric realm. Different educational strategies are needed in the college-age group, as well as the mature group. Similarly, treatment of assaults range from those who will be treated in a pediatric environment and/or hospital to those clearly within the domain of adult centers.

For their methodology, the authors selected a two-year prospective cohort study derived from a consecutive sample of 14- to 24-year-olds that had a history of drug use in the 6 months prior to seeking assault injury care at an urban Level I emergency department. They compared this cohort to a proportionately sampled comparison group of drug using patients who were not assaulted. Both groups were followed for 24 months.

The results of this study show that 59% of the assault injury group reported firearm violence; this frequency was 40% higher than the comparison group. 63% reported at least one event of firearm violence within the first six months.

This was a difficult study for patient accrual; in the 18-or-younger group, written consent, along with parental consent, was needed. Written consent was also obtained for those over 18. The authors utilized a self-administered screening survey, as well as financial inducement—$20.00 scaled up over five visits to $50.00—to encourage participants to continue their involvement in this survey. It is difficult to determine whether or not these inducements biased both the results of the survey and the accuracy of the information. Furthermore, it would have been important to ensure that these surveys were not completed while the participants were under the influence of drugs: both drugs and financial inducements can influence a participant to give information they think authors may want to hear, in order to remain in the study for continued financial gain. The design of this study clearly sends a signal to the readership that its results should be interpreted with caution.

The authors conclude that this is a very real problem with devastating short- and long-term personal and societal implications, which gives validity to their desire to use these teachable moments to educate this population on the danger of firearm violence and its associated morbidity and mortality. It would be very useful for the authors to continue to develop and report their methods and strategies for educating this population on the effects of firearm violence. Similarly, a longitudinal multi-year study measuring the impact of that education, its potential to decrease recidivism of assaults in general, and, specifically, how to modify aggressive and violent behaviors, would be extremely helpful. This is a thoughtful paper that addresses a critically important issue for our society.