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Grossman DC, Mueller BA, Riedy C, Dowd MD, Villaveces A, Prodzinski J, Nakagawara J, Howard J, Thiersch N, Harruff R. Gun Storage Practices and Risk of Youth Suicide and Unintentional Firearm Injuries. JAMA. 2005;293(6):707–714. doi:10.1001/jama.293.6.707
Context Household firearms are associated with an elevated risk of firearm death
to occupants in the home. Many organizations and health authorities advocate
locking firearms and ammunition to prevent access to guns by children and
adolescents. The association of these firearm storage practices with the reduction
of firearm injury risk is unclear.
Objective To measure the association of specific household firearm storage practices
(locking guns, locking ammunition, keeping guns unloaded) and the risk of
unintentional and self-inflicted firearm injuries.
Design and Setting Case-control study of firearms in events identified by medical examiner
and coroner offices from 37 counties in Washington, Oregon, and Missouri,
and 5 trauma centers in Seattle, Spokane, and Tacoma, Wash, and Kansas City,
Cases and Controls Case firearms were identified by involvement in an incident in which
a child or adolescent younger than 20 years gained access to a firearm and
shot himself/herself intentionally or unintentionally or shot another individual
unintentionally. Firearm assaults and homicides were excluded. We used records
from hospitals and medical examiners to ascertain these incidents. Using random-digit
dial telephone sampling, control firearms were identified by identification
of eligible households with at least 1 firearm and children living or visiting
in the home. Controls were frequency matched by age group and county.
Main Exposure Measures The key exposures of interest in this study were: (1) whether the subject
firearm was stored in a locked location or with an extrinsic lock; (2) whether
the firearm was stored unloaded; (3) whether the firearm was stored both unloaded
in a locked location; (4) whether the ammunition for the firearm was stored
separately; and (5) whether the ammunition was stored in a locked location.
Data regarding the storage status of case and control guns were collected
by interview with respondents from the households of case and control firearms.
Results We interviewed 106 respondents with case firearms and 480 with control
firearms. Of the shootings associated with the case firearms, 81 were suicide
attempts (95% fatal) and 25 were unintentional injuries (52% fatal). After
adjustment for potentially confounding variables, guns from case households
were less likely to be stored unloaded than control guns (odds ratio [OR],
0.30; 95% confidence interval [CI], 0.16-0.56). Similarly, case guns were
less likely to be stored locked (OR, 0.27; 95% CI, 0.17-0.45), stored separately
from ammunition (OR, 0.45; 95% CI, 0.34-0.93), or to have ammunition that
was locked (OR, 0.39; 95% CI, 0.23-0.66) than were control guns. These findings
were consistent for both handguns and long guns and were also similar for
both suicide attempts and unintentional injuries.
Conclusions The 4 practices of keeping a gun locked, unloaded, storing ammunition
locked, and in a separate location are each associated with a protective effect
and suggest a feasible strategy to reduce these types of injuries in homes
with children and teenagers where guns are stored.
The presence of a household firearm is associated with an increased
risk of suicide among adults and adolescents.1-6 In
a study of suicide attempters and completers, investigators found that 75%
of the guns were stored in the residence of the victim, friend, or relative.7 The public health importance of household firearms
is a function both of the relative risk of exposure and the prevalence of
firearms in the environment of children and adolescents.8 Schuster
et al9 estimated from the National Health Interview
Survey that 35% of homes in the United States with children younger than 18
years reported owning at least 1 firearm, and that 43% of these homes had
at least 1 unlocked firearm. Reports from other surveys have derived similar
estimates of the fraction of the population at risk from unlocked household
Unloading and locking all guns and ammunition in the home can potentially
reduce access to guns by youth. The policy issue of safe storage of firearms,
both in legislative and clinical approaches, has received much attention in
the medical and public health communities over the past decade.11,12 Existing
evidence supporting this approach to the prevention of firearm injuries among
youth is largely derived from ecological studies of the effects of laws requiring
parents to securely store firearms.13,14 Securely
storing guns is perhaps a more plausible strategy for unintentional gun injuries
among toddlers and young children, but the plausibility of this strategy to
reduce youth suicide is less clear.15 A high
level of intent to harm oneself may lead an actively suicidal youth to defeat
gunlocks and safes.
To date, only a few studies have indirectly addressed if secure firearm
storage is an effective preventive measure for either firearm suicides or
unintentional firearm injuries, but few have had sufficient statistical power
to detect this association.1,3 The
purpose of this study was to measure the association of household firearm
storage practices and the risk of unintentional and self-inflicted firearm
injuries associated with child or adolescent access to firearms in the home.
This study used a case-control design, and the key exposure was firearm
storage practices of guns in households with children. The design was not
population-based due to the referral patterns of decedents and injured victims
to medical examiner offices and trauma centers. The geographic area for both
cases and controls included a convenience sample of 37 counties in the states
of Washington, Oregon, and Missouri. Nonfatal cases were identified in 5 level
I or II trauma centers in the cities of Seattle, Tacoma, and Spokane, Wash,
and Kansas City, Mo. Controls were selected from households having both firearms
and exposure to children and were identified by random-digit dial telephone
A case firearm was identified by involvement in an incident in which
a child or adolescent younger than 20 years gained access to a household firearm
and shot himself/herself or another individual. Only suicide attempts and
unintentional firearm injuries, both fatal and nonfatal, were included. Assaults
and homicides with a firearm were excluded since we believed that gaining
access to a valid source of information regarding the storage status of the
firearm would be hampered by legal constraints. Shootings must have occurred
with a powder firearm such as a handgun, rifle, or shotgun. Shootings with
pellet (“BB”) or air guns were excluded. Because of the method
of control selection, households from which the firearms originated must also
have had working telephones. The reference firearm may have originated from
either the victim’s or shooter’s household or from the household
of a third party.
Potentially eligible shooting incidents were identified through 3 sources:
medical examiners’ offices, coroners’ offices, and trauma centers.
For fatal cases, we queried the offices of medical examiners and coroners
from each of the participating counties on a monthly basis to determine if
any new cases of firearm deaths to youths younger than 20 years had been recorded.
If there was a positive response, these files were reviewed by study staff
to determine if the shooting met criteria for inclusion. The medical examiner
or coroner made the final determination of intent for each shooting. Study
staff reviewed the medical examiner/coroner files, which often included a
death certificate, a scene investigation report, and autopsy and police reports.
In a number of circumstances, further information from police records was
needed to determine if the case met study eligibility criteria, particularly
if the source of the gun was unclear. These records were requested by the
appropriate law enforcement agency and included in the medical examiner/coroner
files for further review. Final determination of eligibility for the study
was made after the interview with representatives of the victim’s household
and/or the household from which the gun originated.
We enrolled cases both prospectively and retrospectively. Potentially
eligible “case” firearms were involved in shooting events that
resulted in a fatal or nonfatal injury from January 1, 1994, to December 1,
2001. Shootings resulting in nonfatal injuries were only identified prospectively
from January 1999 to November 2001. Enrollment for all cases started in January
1999. The earliest shooting incident enrolled in the study occurred in April
To identify firearms involved in nonfatal injuries, we conducted surveillance
at 5 large level I and II trauma centers in 4 cities within the participating
counties. Local coordinators reviewed the emergency department logs at these
institutions monthly to determine if any potentially eligible cases were seen
in the emergency department. All firearm injuries to children and adolescents
were reviewed by the study staff and type of intent (unintentional or suicide)
was determined based on the medical record.
The gun owner (usually, but not always, the victim’s parent) in
all potential case events was contacted by letter from the relevant examiner/coroner
(for fatal cases) or from one of the investigators (D.C.G. or M.D.D., for
nonfatal cases) to introduce the study and to invite participation. A follow-up
telephone call by a study team member was conducted to answer questions and
schedule an interview.
A total of 525 events involving firearms that potentially met criteria
for inclusion as cases were identified from medical examiners, coroners, and
hospitals. Of these, 213 were excluded as homicide/assault incidents and 21
were excluded because of uncertain eligibility. Contacts were attempted with
a total of 291 potential cases. An additional 23 were found to be ineligible
after further information was obtained, leaving 268 who were approached for
an interview. Of these, 64 (24%) refused to be interviewed, 80 (30%) could
not be located or contacted, and 18 (7%) were found to be ineligible after
the interview was completed. A total of 106 of 250 who were potentially eligible
(42%) (or 106 of 170 whom we successfully contacted [62%]) were included as
cases. Of the 106 cases, 82 (77%) were associated with a suicide attempt,
and 24 (23%) were associated with an unintentional firearm injury. Sixty-four
cases were from Washington State, 27 were from Missouri or Kansas, and the
remainder were from Oregon (n = 12), Alaska (n = 1), Idaho
(n = 1), and Montana (n = 1). There were no important
demographic (victim age and sex, respondent sex, injury intent, and outcome)
or circumstantial differences between responders and nonresponders among the
cases, except whether the case was prospectively or retrospectively identified.
A larger proportion of retrospective cases refused to participate or could
not be located.
Control firearms were identified from randomly selected households in
the same counties from which cases were identified. A control was eligible
if there was a firearm stored in or around the house (eg, in the garage, car,
or attached storage area) on the date of the matched gun’s shooting
incident and if there was at least 1 child living or visiting the home at
least 2 or more days per year under adult supervision. We attempted to select
approximately 4 controls for every case, which were frequency matched by age
group (of the shooter) and county of residence. Households in which control
firearms were stored were identified by random-digit telephone dialing in
counties where case guns were stored. The telephone screening was conducted
by a private research firm (Gilmore Research Group, Seattle, Wash) using banks
of residential telephone prefixes. At least 10 different attempts were made
on different days and times to reach a household before listing it as nonresponsive.
When a residence was successfully contacted, the interviewer confirmed that
the responder was an adult household member. A brief screening interview with
several child safety questions was then conducted to identify potential households
with control firearms and child residents or visitors. Eligible respondents
were invited to participate in a second interview with one of the study interviewers.
A total of 37 797 telephone numbers were dialed in the eligible
counties, and 14 840 contacts were made. A total of 6892 (46%) of screening
interviews were refused, and 7320 (49%) completed the screening interview.
Of these, 627 (9%) met eligibility criteria for inclusion as controls. Of
these, we successfully completed a full interview with 493 respondents (79%).
Of these, 480 households with firearms were ultimately determined to be eligible
and were included in the final analyses.
Case firearms were defined as the gun used in the fatal or nonfatal
shooting incident identified during the study period. Since many homes have
more than 1 gun, the control firearms were defined as the household gun most
recently fired or acquired. The key exposures of interest in this study were
whether the subject firearm was locked and/or unloaded and whether its ammunition
was locked and/or stored in a separate location. Additional information was
gathered about the type of extrinsic locking device used, if any. The reference
date used for exposure recall was the date of the shooting incident for cases
or, for controls, January 1 of their respective case’s index year.
Respondents were asked questions about each of up to 5 firearms stored
in the home, beginning with the case or control gun. For each gun, the type
of firearm, purpose, number of years owned, and details of storage (use of
various extrinsic locking devices, whether stored loaded) and ammunition (whether
stored locked, proximity to firearm) were queried. Up to 3 different extrinsic
locking devices were recorded for each firearm, and up to 3 were recorded
for the relevant ammunition.
Firearms were categorized with respect to locking status by the reported
use (use on the reference date and usual use) of any of the following extrinsic
locking devices or practices: trigger lock; lockable box; lockable gun safe,
lockable cabinet or gun rack; lockable non–gun-specific safe or box.
In addition, guns stored in locked drawers, cabinets, or rooms were categorized
as “locked.” A similar strategy was used to categorize ammunition
storage practices. Respondents were also asked whether guns were stored in
the “same location as the ammunition or bullets.” Firearms that
were stored loaded were classified as being in the same location as ammunition.
All data were collected in a structured interview by 1 of 2 experienced
interviewers, either in-person or on the telephone. Both interviewers received
additional training in dealing with bereaved family members. In most instances,
the respondent was one of the adults residing in the house where the gun was
stored. The interview took about 30 minutes. The respondents were shown photographs
of various intrinsic and extrinsic safety devices and firearm types to aid
recall. If the interview was conducted by telephone, the subjects received
a set of photographs by mail prior to the interview. At the completion of
the interview, bereaved families were given an opportunity to talk in open-ended
fashion about the child and the circumstances surrounding his/her injury or
death. If the family desired, written material regarding social and counseling
resources for survivors were provided after the interview.
Participants in this study classified their racial and ethnic background
during the interview process. Participants used categories developed by the
investigators, and these included an option for “mixed race.”
We collected racial and ethnic data to assess the comparability of the case
and control populations in the study. No analyses were performed using race
as a predictor variable.
Analyses to calculate odds ratios (ORs) as estimates of the risk ratio
of a shooting event associated with gun storage practices and use of specific
devices were conducted using multivariable logistic regression, which allowed
evaluation and control of other factors that may have affected the relationships
of interest. Evaluation of confounding included assessment of several factors
for their possible effects on the OR and included (after adjustment for county
of residence and ages of children in the home, variables for which controls
were frequency matched): respondent sex, age, household annual income level,
and education level; type of firearm (handgun vs long gun); sex and age of
the firearm owner; number of other guns stored in the home; and whether the
reference firearm purpose was recreational or for protection. Only those factors
that meaningfully altered the risk ratios (by >10%) were retained in the regression
model. Unless otherwise indicated, all risk estimates were adjusted for county,
ages of children in the home, and type of reference firearm. Analyses were
conducted using SPSS (version 10.5, SPSS Inc, Chicago, Ill) and Egret (version
0.26.6, Cytel Software Corp, Cambridge, Mass) statistical software.
This project was approved by the institutional review board (IRB) of
the University of Washington, the University of Missouri-Kansas City Social
Sciences IRB, and several hospital IRBs prior to the conduct of this study.
All participants gave written informed consent prior to the interviews.
Of the 106 shooting incidents included in the study, there were 82 suicide
attempts (95% fatal) and 24 unintentional injuries (50% fatal).
Respondents from households with case and control firearms were generally
similar with regard to sex, race, and whether they were homeowners or living
in single-family homes (Table 1). Respondents
from households with case firearms were somewhat less likely to be married,
a college graduate, or to have a household income of at least $70 000.
They also had fewer children younger than 20 years living in the home; however,
the number of children living or visiting at least 2 days per year was similar
in both groups.
The median number of firearms stored in homes with case firearms was
4 (interquartile range, 2-8); the median for homes with control firearms was
3 (interquartile range, 2-5, data not shown). Case firearms were more likely
to be owned by a male child (21%) than were control firearms (5%) (Table 2).
Most of the case (49%) and control (51%) firearms were purchased new
or used (25% and 20%, respectively). However, 31% of case guns were primarily
for protection compared with 19% of control guns; 26% of case guns were primarily
for hunting, compared with 45% of control guns. A greater proportion of case
guns (39%) than control guns (27%) had been owned less than 5 years.
Case guns were less likely to be stored unloaded than control guns (OR,
0.30; 95% confidence interval [CI], 0.16-0.56) (Table 3). Similarly, case guns were less likely to be stored locked
(OR, 0.27; 95% CI, 0.17-0.45), stored separately from ammunition (OR, 0.45;
95% CI, 0.34-0.93), or to have ammunition that was locked (OR, 0.39; 95% CI,
0.23-0.66) than were control guns. Relative to firearms that were unlocked
and loaded, those stored locked and unloaded were less likely to be involved
in a shooting (OR, 0.16, 95% CI, 0.08-0.33) after adjustment for region, ages
of children at home, and type of reference firearm [data not shown]).
The effects of accessibility of the gun and ammunition were also evaluated
separately. Having only the ammunition accessible (with the reference firearm
locked) was associated with a reduced risk of a case shooting event (OR, 0.34;
95% CI, 0.17-0.66) relative to having both the gun and ammunition unlocked
(Table 3). Having both gun and ammunition
locked was associated with an OR of 0.22 (95% CI, 0.11-0.44). Having only
the gun accessible, but ammunition locked, had an OR of 0.47 (95% CI, 0.19-1.16)
for a shooting event.
The practice of locking guns with more than 1 device was not associated
with any additional protective effect beyond that observed for use of a single
device. The association of different extrinsic locking devices with involvement
in shooting events was also assessed. Fewer case guns (32.4%) were stored
at the reference date using some sort of locking device compared with control
guns (57.7%). Relative to use of no device, the use of a box or safe (alone
or in combination with another device) was associated with an OR of 0.26 (95%
CI, 0.08-0.84) (Table 3). Use of individual
devices relative to nonuse of that specific device was also assessed after
adjustment for use of other devices, gun loading status, and type of reference
firearm. Although ORs for use of all of the specific devices evaluated were
less than 1, only the use of a lockbox/safe was associated with a statistically
significant decreased OR for a firearm injury.
Although the use of different devices may vary by type of firearm, our
findings related to the 4 main gun storage exposures were generally similar
when analyses were stratified by whether the subject gun was a long gun or
handgun (Table 4). The practices of
keeping the reference firearm unloaded, locked, and the ammunition locked
were all associated with significantly decreased risks of a shooting event
for both types of firearms. With respect to use of different devices, there
were no apparent differences between devices. The ORs associated with the
use of safes or lockboxes were 0.18 (95% CI, 0.04-0.81) for long guns and
0.17 (95% CI, 0.07-0.45) for handguns (data not shown).
Regardless of whether the injury was unintentional or a suicide attempt
(Table 5), case guns were less likely
to be stored locked or unloaded, and case ammunition was less likely to be
Our findings remained essentially unchanged when stratified by the purpose
of gun ownership, the sex of the respondent, or when the analyses excluded
control guns that had never been fired. For the storage practices of keeping
the gun unloaded and locked, the risk estimates were identical regardless
of whether the primary purpose of the reference firearm was protection or
recreation. The greatest difference observed was for the practice of keeping
the gun and ammunition separate when the purpose was recreational (OR, 0.84;
95% CI, 0.42-1.71) vs when the purpose was protection (OR, 0.37; 95% CI, 0.14-0.98
[data not shown]).
The risk estimates for storage practices remained 0.5 or less when analyses
were stratified by respondent sex with 1 exception: when the respondent included
a male, the OR for keeping ammunition locked was 0.60 (95% CI, 0.27-1.31).
When firearms that had never been discharged were excluded, the greatest change
occurred for the practice of keeping the gun and ammunition separate (OR,
0.59; 95% CI, 0.36-0.97). Finally, of the households where case guns were
stored, 23 respondents reported that a child was the primary owner of the
gun. Because parental supervision of gun use may not be as complete in these
instances, we also performed subanalyses restricted to only guns owned by
adults. This restriction had no appreciable effect on the direction or magnitude
of these findings, with the greatest change occurring for the practice of
storing the gun and ammunition separately (OR, 0.64; 95% CI, 0.37-1.11). All
of these subanalyses, however, were limited by small numbers.
Safe storage practices, including keeping firearms stored unloaded,
in a locked place, separate from ammunition, and/or secured with an extrinsic
safety device, were shown to be protective for unintentional firearm shootings
and suicide attempts among adolescents and children. The 4 specific practices
of keeping a gun locked, unloaded, and storing ammunition locked and in a
separate location were each associated with a protective effect and suggest
feasible strategies to reduce these types of injuries in homes with children
and adolescents where guns are stored. These findings appear to be consistent
for both long guns and handguns, as well as for suicides and unintentional
We are unaware of any other case-control studies that sought primarily
to examine the potential protective effects of firearm storage practices for
either adults or children. Several investigators, however, have reported on
these associations as subanalyses of case-control studies designed to investigate
the association between household ownership and the risk of suicide in the
home.1,3 However, those studies
were not designed to explore these specific associations. Our findings support
several ecological studies of the effect of child (firearm) access prevention
laws that showed an association between the law implementation and a reduction
in the rate of youth suicides.13,14
We are unaware of any controlled analytic studies of firearm storage
practices and unintentional firearm injuries among children and adolescents.
Wintemute and colleagues16 reported several
case series of unintentional shootings and documented a high rate of accessible
and loaded household firearms from these homes.
There are a number of limitations to our study. Our findings may not
be generalizable to firearm injuries resulting from homicides and criminal
assaults with firearms and may not be generalizable to geographic regions
not included in the study. Our study may also not be generalizable to adults
or to adolescents living outside of the supervision of their parent. Our narrowly
framed case definition only encompassed situations in which a supervising
adult lived in the same household where the gun was stored and was aware of
the presence of a gun in the household. We were unable to validate the storage
status of the reference firearm; however, none of the states involved in the
study had laws mandating secure storage and we found respondents rarely refused
or were hesitant to disclose the storage status of guns. Furthermore, the
findings of storage practices among our control households were similar to
those reported in other studies of homes with children.9,10,17-19
Recall bias is a potential threat to the validity of studies retrospectively
collecting exposure data. Although we used photographs to aid identification
of locking devices and few respondents appeared to have difficulty recalling
this information, it is possible that memory of past storage practices may
have been less accurate. When evaluated separately by whether respondents
were interviewed within 1 year, or longer than 1 year from the reference date,
risk estimates for storage practices were less than or equal to 0.5 with 1
exception: storing the gun separately from ammunition among those interviewed
within 1 year of the reference date (OR, 0.78; 95% CI, 0.40-1.53).
We addressed the possibility of differential nonresponse to questions
concerning gun storage by conducting subanalyses in which cases with missing
information were first categorized as having answered affirmatively to the
specific storage practices, and subsequently recategorized as having answered
negatively. The largest difference between results given these 2 assumptions
was 0.13, and the greatest OR observed was 0.64 (95% CI, 0.39-1.04) for the
practice of keeping the gun and ammunition separate under the assumption that
all unknown cases had responded affirmatively to this practice; the remainder
were all significantly less than 1.
Sampling bias is a potential concern, given that overall response rates
for cases and controls were lower than expected. An analysis of case nonresponders
(both those who refused to participate and those we could not contact) did
not reveal important differences in demographic variables. The only exception
was if the case was prospectively or retrospectively identified. Stratification
by this variable did not reveal differences. The overall response rate for
control households was also below 50%, reflecting the increasing difficulty
of conducting telephone surveys for surveillance purposes. Our rate was comparable
to a recent report describing the response rates for the Behavioral Risk Factor
Survey sponsored by the Centers for Disease Control and Prevention, in which
the median national response rate for states in 2002 was 58% (range, 42%-83%),
using reporting standards of the Council of American Survey Research Organizations.20 The consequence of declining survey response rates
has not been associated with increased bias for other public health risk factors.21 Finally, since this study did not use suicides from
all causes as the inclusion criteria for subjects, we cannot assess whether
potential attempters who were thwarted from accessing a firearm would complete
suicide by an alternate method, if their intent was sufficiently high.
In summary, storing household guns as locked, unloaded, or separate
from the ammunition is associated with significant reductions in the risk
of unintentional and self-inflicted firearm injuries and deaths among adolescents
and children. Programs and policies designed to reduce accessibility of guns
to youth, by keeping households guns locked and unloaded, deserve further
attention as 1 avenue toward the prevention of firearm injuries in this population.22,23
Corresponding Author: David C. Grossman,
MD, MPH, Department of Preventive Care, Group Health Cooperative, 1730 Minor
Ave, Suite 1600, Seattle, WA 98101 (firstname.lastname@example.org).
Author Contributions: Dr Grossman had full
access to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Grossman, Mueller,
Acquisition of data: Grossman, Mueller, Riedy,
Dowd, Villaveces, Prodzinski, Nakagawara, Howard, Thiersch, Harruff.
Analysis and interpretation of data: Grossman,
Mueller, Riedy, Dowd, Villaveces, Nakagawara.
Drafting of the manuscript: Grossman, Nakagawara,
Critical revision of the manuscript for important
intellectual content: Grossman, Mueller, Riedy, Dowd, Villaveces, Prodzinski,
Statistical analysis: Mueller, Villaveces.
Obtained funding: Grossman, Mueller.
Administrative, technical, or material support:
Grossman, Dowd, Villaveces, Prodzinski, Howard, Thiersch, Harruff.
Study supervision: Grossman, Mueller, Dowd.
Financial Disclosures: None reported.
Funding/Support: Funding for this study was
provided by the Centers for Disease Control and Prevention (grant R49/CCR015592).
Role of the Sponsor: The Centers for Disease
Control and Prevention did not participate in the design and conduct of the
study; in the collection, analysis, and interpretation of the data; or in
the preparation, review, or approval of the manuscript.
Acknowledgment: We wish to acknowledge the
dedicated efforts of Rosalie Ginnett, Sarah Parkhurst, RN, and Lori Thomas,
RN, in the conduct of this study; Lynda Voigt, PhD, MN, for advice on study
design; and Peter Cummings, MD, MPH, and Tom Koepsell, MD, MPH, for their
thoughtful review and comments of earlier drafts. We are also deeply grateful
to the following medical examiners, coroners, and trauma managers for their
assistance with the study: Gina M Fino, MD; Nikolas Hartshorne, MD (deceased);
Tammy Retzloff, RN; Ted Walkey, MD; Dennis Wickham, MD. Eve Adams provided
expert assistance with the preparation of the manuscript.