This study describes alcohol involvement in violent deaths using the National Violent Death Reporting System (NVDRS) from 2015 to 2022 in 24 states where at least 90% of decedent records had available alcohol assessment data. Using a repeated cross-sectional design, we construct a composite alcohol-involvement measure from toxicology results and NVDRS coder assessments and estimate negative binomial regression models with state-year demographic population counts as offsets to evaluate the roles of alcohol, firearms, and their intersection in violent deaths. The analytic sample included 204,739 decedents. Alcohol was present in roughly 27% of all violent deaths (27% in suicide and 25% in homicide deaths), with age- and sex-adjusted alcohol-involved mortality rates ranging from 1.6 per 100,000 in Virginia to 7.8 per 100,000 in North Dakota. Firearms and alcohol co-occurred in 19% of homicide and 14% of suicide deaths. Alcohol involvement was most common among men and younger adults (aged 20-39) with the highest rates observed for men aged 30-39 who died from suicide. There was a slight (6%) decrease in mean alcohol-involved violent death rates within a subsample of 18 states observed from 2016 to 2022, although Alaska saw a larger decrease (39%) and Oregon and Connecticut saw a near doubling of their alcohol-involved violent death rates over this period. These findings indicate that alcohol plays a substantial and complex role in violent deaths. This role differs between homicides and suicides, and varies by sex, age, state, year, and firearm involvement. Violence reduction efforts may benefit from interrupting the links between alcohol consumption and violent behaviors. Improved data collection and toxicology standardization across states would greatly enhance efforts to monitor and evaluate ongoing and future interventions.

BackgroundShoulder girdle injuries are common musculoskeletal conditions that frequently require medical attention and may result in substantial functional impairment and healthcare utilisation. While many cases are managed on an outpatient basis, a relevant proportion requires inpatient care. Comprehensive nationwide analyses of inpatient shoulder girdle injuries over extended time periods remain limited, particularly with regard to recent healthcare disruptions such as the COVID-19 pandemic.MethodsThis nationwide, population-based, retrospective study analysed aggregated inpatient hospital discharge data from the German Federal Health Monitoring system (GBE-Bund). Inpatient hospitalisations for shoulder girdle injuries were identified using ICD-10-GM code S43 as the primary discharge diagnosis. The primary analysis covered the continuous annual period from 2010 to 2023, with data from 2000 and 2005 presented as historical reference years. Population-based hospitalisation rates per 100,000 inhabitants were calculated using official population statistics. Analyses were descriptive and included predefined age-stratified subgroup analyses.ResultsBetween 2010 and 2023, the annual number of inpatient shoulder girdle injury hospitalisations declined from 23,549 to 17,532 cases. Correspondingly, the population-based hospitalisation rate decreased from 28.8 to 21.0 per 100,000 inhabitants. Hospitalisation rates remained largely stable during the early observation period, followed by a gradual decline and a pronounced reduction in 2020, coinciding with the COVID-19 pandemic. A partial recovery was observed in subsequent years, with rates remaining below pre-pandemic levels. Throughout the study period, inpatient hospitalisations were consistently more frequent in males than in females. Age-stratified analyses showed that inpatient hospitalisations were highest in patients aged 15–44 years, followed by ≥ 65 years and 45–64 years, respectively. The mean length of hospital stay declined steadily from 3.9 days in 2010 to 2.9 days in 2023.ConclusionsNationwide inpatient hospitalisations for shoulder girdle injuries in Germany declined overall during the observation period, accompanied by a substantial reduction in length of hospital stay and a persistent male predominance. The marked decline observed during the COVID-19 pandemic and incomplete recovery thereafter highlight evolving patterns in hospital-based trauma care. These findings provide contemporary population-based epidemiological benchmarks and are relevant for healthcare planning and resource allocation.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40621-026-00668-3.

BackgroundHelmet-preventable head injuries are a common cause of snowmobiling-related injury. Our objective was to determine the demographics, helmet use, and attitudes regarding snowmobile helmet use among rural adolescents.MethodsAn anonymous survey was administered to a convenience sample of adolescents (ages 13–18) at the 2022 Iowa FFA Leadership Conference. Frequency and comparative analyses were performed.ResultsOf the 1,331 respondents, 58% were female and 96% non-Hispanic White. One-half lived on farms, 21% lived in the country/not on a farm, and 28% lived in town. One-quarter (26%) lived in households owning a snowmobile, with higher ownership among farm residents (31%) compared to those in the country/not on a farm (23%) or in town (19%), p < 0.001. Over one-third of participants had ridden in the past year. Riding was more common amongst males, Caucasians, farm residents, and those from households owning snowmobiles (all p ≤ 0.01). Frequent riding (at least weekly) was higher among older teens and snowmobile-owning households (p = 0.025 and p < 0.001, respectively). Helmet use was: 67% always/mostly, 11% sometimes, and 21% rarely/never. The importance of snowmobile helmet use (from 1 to 10) was highly rated (median, 9; mean, 8.2). Relative to their peers, females (p = 0.018), those owning snowmobiles (p < 0.001), and frequent riders (p < 0.01) had greater proportions wearing helmets always/most of the time, and rated the importance of helmet use more highly. 59% supported snowmobile helmet laws.ConclusionWhile most rural adolescents value snowmobile helmet use and support legislation, nearly half report inconsistent use. Importantly, our study identified demographic groups for targeted interventions.

ObjectivesTo conduct a scoping review of research on government spending and violence.MethodsWe searched nine databases for peer-reviewed publications evaluating the association between government spending on public goods and services and (other- or self-directed) violent physical injury or death in the United States.ResultsOf 5,734 screened articles, 33 met the inclusion criteria. Over one-third of studies were published in the last ten years (n = 13). Studies most commonly evaluated spending at the state (n = 19), county (n = 5), and city (n = 5) levels. Studies examined spending on social welfare (n = 21), health (n = 12), education (n = 9), law enforcement (n = 8), and/or community development (n = 2). Outcomes were homicide/assault (n = 28) and suicide (n = 17). All studies were ecologic, 24 were serial cross-sectional, and most (n = 28) made attempts to control for confounding. Findings were mixed, but studies of social welfare, health, and education most commonly found that increased spending was significantly associated with reductions in violence.ConclusionsWhile research has varied somewhat in methodology and findings, results of this scoping review indicate that government investments in supportive services may be promising structural interventions to prevent violence and promote safety and health.

BackgroundCommunity violence intervention (CVI) is increasingly considered an important component of comprehensive public safety infrastructure, but research and evaluation of CVI programs remain underdeveloped. There is a critical need for evaluation measures that are developed collaboratively with those most proximate to these interventions and that capture interventions' nuanced and holistic impacts. This paper presents the process and results of a practitioner-academic partnership to co-develop youth-focused CVI evaluation measures in Washington state.ResultsThe process of co-developing evaluation measures involved two phases. For phase 1, we created a menu of quantitative measures (n = 60) for each outcome construct in a previously co-developed CVI theory of change by integrating existing measures, identified through a literature review, with insights and recommendations from CVI practitioners gathered during a workshop. For phase 2, we tailored and refined quantitative and qualitative measures with/for 7 CVI programs involved in the collaboration via individual meetings (n = 45 one-hour meetings over the course of 10 months, average = 6.4 meetings per program). The process of refining measures involved extensive discussion around several key considerations, including confidentiality, age appropriateness of questions, and language/jargon. After revisions, each CVI program had a customized list of quantitative and qualitative measures that fit their program and the population they served. We also created an online toolkit accompanying this paper so others may easily use, tailor, and build upon our work.ConclusionsOur process of co-developing youth-focused CVI evaluation measures drew from existing literature while heavily prioritizing the knowledge, expertise, and capacity of CVI practitioners. This helped facilitate power sharing and responsiveness to community needs, and we believe it resulted in more appropriate and contextually relevant measures. By detailing the iterative process that we took along with the resulting evaluation measures, our intent is to encourage practitioner-academic collaboration and underscore how such partnerships can enhance the field’s understanding of CVI implementation and impacts.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40621-025-00642-5.

BackgroundMotor vehicle crashes and resultant fatalities remain disproportionately high among young drivers, with crash risk peaking immediately after licensure. Although graduated driver licensing laws (GDL) for young novice drivers have reduced such fatalities, driver error remains a leading cause; thus, prevention efforts that target improving skills in novice teen drivers before licensure are a strong candidate for reducing crash risk early in licensure. States with more comprehensive driver licensing laws that include mandated driver training before licensure in addition to GDL show lower crash rates post-licensure, but these effects were not determined through rigorous controlled studies of driver training. This paper describes the DRIVER study, a phase III randomized trial that tests the effectiveness of two different driver training programs in reducing young driver crash risk early in licensure in Pennsylvania, a state like many others that does not require formal training for young drivers.MethodsLearner drivers age 16 and 17 years will be recruited and followed through the GDL learner phase and for six months post-licensure. Participants will be randomly assigned to one of three interventions: professional behind-the-wheel training (n = 333), online hazard training (n = 333), or an active control online vehicle and driver safety course, unrelated to hazard skills training (n = 333). The primary outcomes are on-road crash risk post-licensure (via kinematic hard braking events tracked through a smartphone-based app) and state license examination performance. Secondary outcomes include change in simulated driving performance from baseline to the time of license examination, self-reported and kinematically tracked risky driving behavior (e.g. cell phone use, speeding) and self-reported crashes. Participants will complete baseline surveys and cognitive assessments to determine potential moderating effects of cognitive maturation and risk-taking tendencies.DiscussionFindings from the DRIVER study will provide insights into training effectiveness generally, and an evidence base for recommendations to policy makers, while also revealing for whom these interventions are less effective.Trial registrationThe study was registered on ClinicalTrials.gov Registry (NCT06413927) in May 2024, https://clinicaltrials.gov/study/NCT06413927 and last updated on August 11th, 2025. This protocol was developed per the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Checklist.

ObjectiveThis study evaluated the excess out-of-hospital healthcare costs associated with unintentional childhood injuries in Australia. This relationship was investigated within a longitudinal biennially surveyed cohort of 8,852 children aged 0–19 years. We assessed whether costs increased over age and with the duration of injury prevalence. Results were compared against cost estimates from similar studies in Australia and analogous developed nations.Data sources and study settingThe nationally representative Longitudinal Study of Australian Children provided linked Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) cost data for the Birth and Kindergarten cohorts, followed for 15 years.Study designWe used a mixed effects generalized linear model (GLM) with a gamma distribution and log link to estimate outpatient healthcare costs and assess the effect of injury status, controlling for sociodemographic characteristics. This model accounted for repeated measures over time and variability both within and between individuals.ResultsAnnual excess outpatient and pharmaceutical costs for injuries among 0–19 year-olds were A$39.1 million for those who were hospitalised and A$104.8 million for those only requiring community-based treatment. These estimates do not include inpatient hospital costs, which are not captured in the Medicare dataset.ConclusionsUnintentional childhood injuries in Australia incur significant financial burden on the public healthcare system, with costs per capita higher than other childhood conditions. Our figures are likely an underestimate. These excess healthcare costs support preventive efforts to reduce injury incidence among children.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40621-025-00582-0.

BackgroundAccess to lethal means contributes significantly to suicide completion. Lethal means safety counseling (LMSC) is an injury prevention strategy to limit access to firearms, medications, and other means of injury. Not previously evaluated in the trauma setting, this study aims to design and implement a standardized LMSC protocol for pediatric patient discharge education in emergency (ED), trauma, and inpatient psychiatry settings.MethodsA single-center quality improvement study at an academic pediatric urban tertiary Level-one trauma center was performed from July 2023 to February 2024. Protocol was implemented for pediatric patients discharged from three departments: ED, surgery trauma service, and psychiatry. Interventions included electronic medical record (EMR) based LMSC screening questions, training with Counseling on Access to Lethal Means (CALM) module, a de novo educational training video, and providing families free cable gun locks and medicine lock boxes. Healthcare collaborators completed pre- and post-training surveys. Data was recorded in Redcap and analyzed as descriptive and parametric data. Primary outcome was incorporation of LMSC and intervention into social worker’s workflow. Secondary outcomes included project barriers and outcomes, familial impression of counseling, and healthcare provider impression of intervention.ResultsOut of forty-eight persons, 29 providers completed the pre-training survey and 17 completed the post-training survey. Results indicated increased discussions with caregivers about safe medicine storage comparing averages of pre and post-test results (mean difference 0.44, 95% CI 0.05–0.83, p = 0.029), but no differences in discussions about safe firearm storage (mean difference 0.50, 95% CI − 0.05–1.05, p = 0.07) or knives (mean difference 0.56, 95% CI 0.05–1.18 p = 0.07). Provider behavior changes occurred with increased clinical frequency of cable gun lock distribution.ConclusionsThis study describes implementing a standardized LMSC protocol in three pediatric hospital departments with self-reported provider improvements in LMSC. Barriers identified to protocol implementation are an opportunity to improve future preventative patient care.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40621-025-00599-5.

BackgroundAutism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent challenges in communication and social interaction and, often accompanied by restricted and repetitive patterns of behavior and interests. The reported prevalence of ASD in the United States has tripled in the past two decades. Recent studies indicate that ASD is associated with increased self-injurious behaviors. The purpose of this study is to assess the excess risk of intentional self-harm associated with ASD.MethodsUsing a repeated cross-sectional study design, we analyzed data from the 2016–2020 Nationwide Emergency Department Samples (NEDS), the largest all-payer emergency department (ED) database in the United States. ED visits for intentional self-harm were identified using the ICD–10–CM external cause-of-injury matrix. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of ED-treated intentional self-harm associated with ASD in the presence or absence of co-occurring attention-deficit hyperactivity disorder (ADHD) and/or intellectual disability (ID) were estimated through multivariable logistic regression.ResultsThe 2016–2020 NEDS recorded an unweighted total of 159,590,866 ED visits, of which 2,570,446 (1.6%) were related to intentional self-harm. Using weighted data, intentional self-injury accounted for 2.3% of ED visits made by patients with a diagnosis of ASD, 3.9% of ED visits by patients with a diagnosis of ADHD, and 3.3% of ED visits by patients with a diagnosis of ID. Compared to patients without ASD or ADHD/ID, patients with ASD alone had a 65% increased odds of intentional self-harm (aOR = 1.65; 95% CI: 1.60, 1.70); in addition, patients with ADHD/ID but no ASD a 186% increased odds (aOR = 2.86; 95% CI: 2.83, 2.88), and patients with both ASD and ADHD/ ID a 170% increased odds (aOR = 2.70; 95% CI: 2.58, 2.82) of intentional self-harm. Poisoning accounted for 82.3% of the intentional self-harm-related ED visits among patients without ASD and 61.0% of intentional self-harm-related ED visits among patients with ASD.ConclusionsASD is associated with a significantly increased risk of ED-treated intentional self-harm, particularly in patients with co-occurring ADHD or ID. Poisoning from psychotropic and other pharmaceutical drugs is the leading mechanism of intentional self-harm.

BackgroundInterpersonal violence is a pressing public health problem in the United States. Those who interact with the criminal legal system are likely to experience multiple intersecting risks that increase the probability of subsequent violence perpetration. To inform development and implementation of risk-reduction interventions within the criminal legal system or for those involved in it, there is a need for contemporary population-level estimates of violence perpetration risk among those with prior criminal charges or convictions.MethodsIn this state-wide retrospective cohort study of individuals in Washington state, we estimated the risk of future violent and firearm-related charges and convictions among those with misdemeanor charges or convictions for violence-related (including domestic violence), firearm-related, and substance use-related offenses from 2015 to 2019 compared to those with infractions. Subdistribution Hazard Ratios (sdHR) were used to quantify relative risk.ResultsSample sized varied across comparisons, ranging from 766 people with an index firearm-related conviction to 1,280,070 with an index infraction. Relative risk of outcomes ranged from 11.73 (95% CI = 9.08–15.14) (comparing risk of subsequent violent crime conviction among those with index drug/alcohol misdemeanor convictions vs. infractions) to 155.23 (95% CI = 136.87–176.07) (comparing risk of subsequent violent crime conviction among those with index domestic violence-related misdemeanor convictions vs. infractions). Individuals with domestic violence-related misdemeanor convictions had over 30 times the risk of subsequent firearm-related charges and convictions compared to those with infractions.ConclusionsFindings from this state-wide study inform opportunities to reduce risk for subsequent violence and firearm-related harm, for example through tailored intervention, investment in healing-centered deflection strategies, and improved implementation of domestic violence firearm prohibitions.