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Suicide is the 10 leading cause of death in the United States, with firearms reported as the cause of death in up to 50% of these cases. Our goal was to evaluate the feasibility of the Counseling on Access to Lethal Means intervention in the Emergency Department (CALM-ED) by non-physician personnel. We conducted this single-center, prospective, quality improvement study (QI) in an urban, academic ED with over 90,000 annual patient visits. The study looked at adult patients who were discharged after presenting to the ED with suicidal crisis. Assessment of access to lethal means was conducted at the bedside, followed by a counseling session regarding safe storage of lethal means and follow-up via telephone call 48-72 hours after ED discharge. We collected data on patient's sociodemographics, psychiatric history, access to lethal means, lethal means storage methods, the patient's specific plans for lethal means storage after discharge, and post-discharge follow-up care. Of 215 eligible patients, 166 voluntarily agreed to participate in CALM-ED, of whom 84 (51%) reported access to lethal means. Following the intervention, 75% of patients described a specific storage plan for their lethal means. Patients with and without access to firearms were equally likely to participate in the follow-up telephone call. An ED-based CALM QI intervention is feasible for implementation by non-physician personnel and is well received by patients and families. This intervention has the potential to help saves lives at times of suicide crisis.

Key Points Mutations that affect the adaptor molecule SLAM-associated protein (SAP) lead to the genetic disorder X-linked lymphoproliferative syndrome (XLP), which is characterized by severe, often fulminant infections with Epstein–Barr virus, lymphoproliferative disorders (including lymphomas) and dysgammaglobulinaemia that can progress to hypogammaglobulinaemia. SAP is required for signalling downstream of members of the signalling lymphocytic activation molecule (SLAM) family of immunomodulatory receptors. Examination of humoral responses in SAP-deficient mice has shown impaired germinal-centre formation and severely reduced numbers of long-lived plasma cells and memory B cells. Similar findings have now been confirmed in humans with XLP. New findings from in vivo intravital imaging have revealed that SAP-deficient CD4 + T cells show normal adhesion to and activation by dendritic cells but impaired adhesion to activated B cells. These findings suggest that SAP-deficient CD4 + T cells cannot deliver contact-dependent signals that are required for B-cell proliferation and germinal-centre formation, providing new insights into the defects associated with SAP deficiency. SAP is also required in mice for the development of natural killer T (NKT) cells and other innate T-cell lineages that are selected by haematopoietic cells in the thymus (specifically, innate T-cell populations that are selected by double-positive thymocytes). A lack of NKT cells has also been confirmed in patients with XLP. Whether and how these effects on innate T-cell lineages affect the phenotypes of XLP are not clear, but patients with a variant of XLP that is caused by mutations that affect a different gene also lack NKT cells. These findings suggest that SAP and SLAM family members affect the lymphocyte interactions that are required for development and differentiation, and raise the question of how defective lymphocyte–lymphocyte adhesion contributes to phenotypes that are associated with XLP. This article discusses the recently identified role of SLAM-associated protein (SAP) — which mediates signals from signalling lymphocytic activation molecule (SLAM) receptors — in regulating interactions between lymphocytes in the thymus and germinal centres, and suggests that SAP and SLAM family members have roles in lymphocyte adhesion that affect development and differentiation. Mutations that affect the adaptor molecule SLAM-associated protein (SAP) underlie the primary immunodeficiency disease X-linked lymphoproliferative syndrome. SAP is required for mediating signals from members of the signalling lymphocytic activation molecule (SLAM) family of immunomodulatory receptors. Recent data have highlighted a role for SAP in the development of innate-like T-cell lineages, including natural killer T cells, and in the regulation of the interactions between B cells and T cells that are required for germinal-centre formation and long-term humoral immunity. These data have revealed that SLAM family members and SAP have crucial roles in regulating lymphocyte interactions and adhesion, which are required for the normal development, homeostasis and function of the immune system.

Suicide is the 10th leading cause of death in the United States. An estimated 50% of these deaths are due to firearms. Suicidal ideation (SI) is a common complaint presenting to the emergency department (ED). Despite these facts, provider documentation on access to lethal means is lacking. Our primary aim was to quantify documentation of access to firearms in patients presenting to the ED with a chief complaint of SI. This was a cross-sectional study of consecutive patients, nearly all of whom presented to an academic, urban ED with SI during July 2014. We collected data from all provider documentation in the electronic health record. Primary outcome assessed was whether the emergency physician (EP) team documented access to firearms. Secondary outcomes included demographic information, preexisting psychiatric diagnoses, and disposition. We reviewed 100 patient charts. The median age of patients was 38 years. The majority of patients had a psychiatric condition. EPs documented access to firearms in only 3% of patient charts. EPs do not adequately document access to firearms in patients with SI. There is a clear need for educational initiatives regarding risk-factor assessment and counseling against lethal means in this patient cohort.

Introduction: There are more than 80,000 emergency department (ED) visits for non-fatal bullet- related injuries (BRI) per year in the United States. Approximately half of these patients are discharged home from the ED. Our objective in this study was to characterize the discharge instructions, prescriptions, and follow-up plans provided to patients discharged from the ED after BRI. Methods: This was a single-center, cross-sectional study of the first 100 consecutive patients who presented to an urban, academic, Level I trauma center ED with an acute BRI beginning on January 1, 2020. We queried the electronic health record for patient demographics, insurance status, cause of injury, hospital arrival and discharge timestamps, discharge prescriptions, and documented instructions regarding wound care, pain management, and follow-up plans. We analyzed data using descriptive statistics and chi-square tests. Results: During the study period, 100 patients presented to the ED with an acute firearm injury. Patients were predominantly young (median age 29, interquartile range 23-38 years), male (86%), Black (85%), non-Hispanic (98%), and uninsured (70%). We found that 12% of patients did not receive any type of written wound care instruction, while 37% received discharge paperwork that included instructions to take both an NSAID and acetaminophen. Fifty-one percent of patients received an opioid prescription, with a range from 3-42 tablets (median 10 tablets). The proportion of patients receiving an opioid prescription was significantly higher among White patients (77%) than among Black patients (47%). Conclusion: There is variability in prescriptions and instructions provided to survivors of bullet injuries upon ED discharge at our institution. Our data indicates that standardized discharge protocols could improve quality of care and equity in the treatment of patients who have survived a BRI. Current variable quality in discharge planning is an entry point for structural racism and disparity.