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The Joint Theater Trauma Registry is a standardized, retrospective data collection system for all echelons of combat casualty care. Military-specific data elements include expanded demographic data to include military branch, service, rank, military occupation, and personal protective equipment. Varying data from each echelon are entered into the Joint Theater Trauma Registry, version 3. The Joint Theater Trauma Registry, version 3 at the echelon 4 medical treatment facility requires routine collection of 367 data elements for each casualty, but casualties sustaining burns, deaths, or those with performance improvement issues may have more than 450 data elements recorded. Trauma registries are powerful tools for process improvement. Collaboration between civilian and military trauma programs may foster improvements in registry design and data collection for both groups. [ABSTRACT FROM AUTHOR]

The Joint Theater Trauma System (JTTS) is a formal system of trauma care designed to improve the medical care and outcomes for combat casualties of Operation Iraqi Freedom and Operation Enduring Freedom. This article describes the JTTS Trauma Performance Improvement Plan and how JTTS personnel use it to facilitate performance improvement across the entire continuum of combat casualty care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The goal was to use a national database to determine the incidence of abusive traumatic brain injuries (TBIs) and/or fractures and the frequency of abuse versus accidents among children <36 months of age. METHODS: We used the 2006 Kids' Inpatient Database and classified cases into 3 types of injuries, that is, (1) TBI only, (2) TBI and fracture, or (3) fracture only. Groups 2 and 3 were divided into 3 patterns, that is, (1) skull fractures, (2) skull and nonskull fractures, or (3) nonskull fractures. For each type and pattern, we compared abuse, accidental falls, other accidents, and motor vehicle accidents. RESULTS: The incidence of TBIs and/or fractures attributable to abuse was 21.9 cases per 100 000 children <36 months of age and 50.0 cases per 100 000 children <12 months of age. In the abuse group, 29.9% of children had TBIs only, 28.3% TBIs and fractures, and 41.8% fractures only. Abused children were younger and were more likely to be enrolled in Medicaid. For TBI only, falls were more common than abuse in the first 2 months of life but abuse was more common from 2 to 7 months. For TBI and skull fracture, falls were more common during the first year of life. For skull fracture only, almost all injuries were attributable to falls. CONCLUSIONS: There was overlap in TBIs and fractures attributable to abuse. Among <12-month-old children, TBIs and/or fractures attributable to abuse occurred in 1 of 2000. Falls occurred more commonly than abuse, even among very young children. [ABSTRACT FROM AUTHOR]

Metatarsal fractures are one of the most common injuries of the foot, accounting for approximately 5% to 6% of all fractures confronted in the outpatient setting 1 . Approximately 45% to 70% of these fractures involve the fifth metatarsal, which have been described using a 3 zonal approach in 1993 by Lawrence and Botte 2 . Zone 2 fractures are difficult to manage given their retrograde vascular supply, leading to higher rates of nonunion 1,3 . Jones fractures (zone 2) are primarily treated surgically, with the 2 main methods being intramedullary screw fixation and plate fixation 3 . Surgical management leads to higher rates of union when compared with nonoperative modalities. Presented here is a technique for zone 2 intra-articular Jones fractures with minimal to moderate displacement via open reduction and internal fixation. This technique is not recommended for comminuted fractures or those with proximal split fractures. Starting with the foot lateral, this technique requires meticulous marking of the anatomical landmarks of the distal fibula as well as the fifth metatarsal to establish the precise starting point for the guidewire. Using a mini c-arm, a high and inside positioning should be confirmed prior to advancing the guidewire from proximal to distal while remaining positioned in the center of the medullary canal. Capitalizing on the variable pitch of a 5.0-mm headless compression screw, the Jones fracture is compressed to ensure primary bone healing. The incision is then closed, and a soft wrap is utilized followed by 2 weeks of non-weight-bearing and progressive protective weight-bearing until a complete recovery is achieved., Background: Open reduction and internal fixation (ORIF) for the operative treatment of zone-2 intra-articular Jones fractures with minimal to moderate displacement is recommended because of the high rate of nonunion associated with nonoperative treatment. The blood supply to this region is minimal because of its retrograde flow, leading to high rates of nonunion with nonoperative treatment. The presently described technique offers reduction and fixation of a zone-2 fracture, as well as improved functional outcomes and nonunion rates. This approach is minimally invasive, as it is performed percutaneously, leading to a decrease in soft-tissue damage, infection rates, and operative time., Description: The zone-2 fifth metatarsal ORIF technique begins with the use of a marking pen to outline the distal fibula and the head of the fifth metatarsal for proper orientation. Fluoroscopy is utilized to identify the landmarks so that a guidewire can be placed into the proximal dorsal aspect of the fifth metatarsal. Placement is confirmed on multiple radiographic images. The guidewire is then slowly inserted down the medullary canal of the fifth metatarsal, with placement verified on multiple fluoroscopic images. Once placement is confirmed, screw size is estimated with use of radiographic measurements. An incision is made bluntly and dissected down, going high and medial in order to protect the sural nerve and the peroneus brevis tendon insertion. The path is then drilled with use of a cannulated screw system. Biomechanically, a full-core screw is preferable, ranging from 4.5 to 5.5 mm depending on the canal diameter. For the example procedure shown in the video, a full-core 5-mm screw was inserted until appreciable reduction of the fracture was observed on fluoroscopic visualization, with additional confirmation on multiple radiographic views. Once satisfied with the placement, the guidewire is removed and the site is irrigated and closed with use of 3-0 nylon suture. A weight-based combination of short and long-acting local anesthetics (ropivacaine and lidocaine) is then injected around the incision site as part of a postoperative multimodal pain regimen. The area is then cleaned and dried. Xeroform, 4 × 4s, Army battle dressings, and a soft wrap are then applied, followed by a postoperative boot., Alternatives: Poor surgical candidates include those with neuropathic feet, local infection, presence of severe vascular insufficiency, and comorbidities that would make surgery dangerous. Such patients can undergo nonoperative treatment, which includes 4 to 6 weeks of non-weight-bearing in a cast until union is confirmed radiographically. Once union is confirmed, patients undergo 4 to 6 more weeks of weight-bearing in a boot. One meta-analysis found that nonoperative treatment led to nonunion rates between 15% and 30%, notably higher than with operative treatment (0% to 11%) 6 . Most cases of zone-2 fifth metatarsal fracture are treated operatively, with intramedullary screw or plate fixation being the primary techniques. Intramedullary screw fixation is the technique featured in the present video, and offers the advantage of decreased soft-tissue injury, infection, and operative time because of its percutaneous approach. Percutaneous screw fixation is not recommended for comminuted fractures or those with proximal-split fracture patterns 7,8 . Fractures with these patterns should be critically evaluated with additional radiographic work-up. ORIF utilizing hook plates or fracture-specific plate implants may be warranted in these cases. In cases of chronic nonunion or fractures with sclerotic margins, an additional percutaneous incision over the fracture site is recommended to fenestrate the fracture edges and allow bone grafting prior to screw insertion 7,8 ., Rationale: ORIF of zone-2 intra-articular Jones fractures with minimal to moderate displacement with use of an intramedullary screw is a low-risk and highly successful surgical approach to these common fractures. Because of the watershed region at zone 2 of the fifth metatarsal, nonunion rates with nonoperative treatment are relatively high (between 15% and 30%) 4,6 . Another study of 22 patients showed a 100% union rate following operative treatment of acute Jones fracture 5 . These studies, along with others, provide strong evidence to suggest the benefit of early operative treatment with use of screw fixation, as compared with nonoperative treatment., Expected Outcomes: Postoperatively, these patients are managed with a standard protocol established by our institution. The first 2 weeks include being in a soft wrap and postoperative boot while being non-weight-bearing. The patient should keep the incision clean and dry, elevate the foot/ankle often, and follow activity guidelines. Sutures are removed at 2 to 6 weeks postoperatively, and the boot should be used for all weight-bearing ambulation, with crutches being utilized for the transition. Additionally, ankle range-of-motion exercises and strengthening should begin. Weight-bearing should transition as follows: 25% at week 3, 50% at week 4, 75% at week 5, and 100% at week 6. At weeks 6 to 8, walking and physical therapy should be increased and previous exercises should be continued. At weeks 8 to 12, pool or treadmill activity should begin, and it should be increased thereafter. Patients should expect evidence of radiographic union between weeks 6 and 10, with a meta-analysis showing union rates with screw fixation between 89% and 100% 6 ., Important Tips: Guidewire insertion should be proximal and dorsal, allowing the guidewire to enter at the high and inside position. To do so, palpate the proximal aspect of the fifth metatarsal and outline the contour on the skin, then mark the incision 1 to 3 cm proximal to this to avoid unnecessary soft-tissue tension and potential wound issues. This incision is parallel and generally inferior to the sural nerve, but arborization and branching are highly variable. Utilizing a high and inside starting point avoids the more lateral and plantar insertion of the peroneus brevis. The high and inside starting point is verified under anteroposterior, lateral, and oblique radiographic views. This position biomechanically avoids plantar gapping and reduces the risk to soft-tissue structures.Utilizing a mini c-arm or fluoroscopy unit allows multiple views for ideal screw alignment to be obtained quickly, with decreased radiation exposure.Utilizing an all-cannulated system allows for a seamless transition from drilling to screw placement.Avoid making the incision too close to the proximal aspect of the fifth metatarsal, as this would cause unnecessary soft-tissue tension and potential wound issues. The incision should be made 1 to 3 cm proximal to the proximal aspect of the fifth metatarsal.Use adequate soft-tissue retraction, as protecting the sural nerve is paramount during screw insertion.Do not allow the patient to be weight-bearing immediately. We strongly recommend that the patient be non-weight-bearing for 2 weeks and then perform progressive protected weight-bearing in a postoperative boot for 4 weeks., Acronyms and Abbreviations: AP = anteroposteriorABD = abdominal gauze dressingDVT = deep vein thrombosis., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A474)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The introduction of Emergency Medicine in Rwanda in 2015 has been associated with a mortality reduction in patients presenting to Kigali University Teaching Hospital (KUTH). In the context of increasing numbers of critically ill patients presenting to Emergency Departments (ED) globally, the aim of this study was to describe the characteristics of critically ill patients, the critical care interventions performed, and the outcomes of critically ill patients presenting to the KUTH ED with the goal of informing future research into the root causes of mortality of critically ill ED patients and of identifying high yield topics for didactic and procedural training., Methods: A descriptive observational prospective cohort pilot study analyzed all patients ≥15 years who presented to KUTH between April and June 2022 with modified South African Triage Scores of Red with alarm, Red without alarm, and Orange., Results: Of 320 patients, 66.9% were male and median age was 40 years. Patients were triaged as Orange (65.3%), Red without alarm (22.8%), and Red with alarm (11.9%). Presentations were categorized as: medical emergencies (48.0%), traumatic injury (44.5%), and surgical emergencies (7.6%). Median length of stay was 31 h (IQR 28, 56) and boarding was 23 h (IQR 8, 48). Overall mortality was 12.2% and highest among medical emergencies (16.5%, p = 0.048) and increased significantly with triage color: Red with alarm (47.4%), Red without alarm (16.4%), and Orange (4.3%, p < 0.0001). Cardiopulmonary resuscitation (CPR) (10.3%), endotracheal intubation (8.8%), and vasopressor administration (3.1%) were the most frequent critical interventions performed. Survival after cardiac arrest was 9.1% and 32.1% after intubation. Mortality was associated with the following interventions: CPR, intubation, and use of vasopressors (p < 0.05)., Conclusions: This pilot study identified the most common critical care interventions performed and a high mortality among patients who required these interventions in the ED of a tertiary teaching hospital in Rwanda. These findings will inform didactics and procedural training for emergency care providers. Future research should focus on the root causes of mortality in these specific patient populations and identify areas of system strengthening to reduce mortality., (© 2024. The Author(s).)

Objective:  Studies have suggested an association between prenatal care (PNC) and preterm birth (PTB). We evaluated trends in PTB and association of PNC and PTB., Study Design:  This was a retrospective cohort study of singleton, viable nonanomalous deliveries from 1991 to 2018. PNC utilization was defined by World Health Organization using number of visits: adequate (≥8), suboptimal (5-7), and inadequate (<5). Primary outcome was PTB. Tests of trend were used to assess changes in PTB over time. Baseline characteristics and outcomes were compared. Logistic regression estimated the association of PNC and PTB. We evaluated for effect modification by year of birth., Results:  Of 92,294 patients, 14,057 (15%) had PTB. Inadequate and suboptimal PNC were associated with higher odds of PTB compared to adequate PNC (adjusted odds ratios = [aOR 6.21], 95% confidence interval [CI]: 5.84-6.60; aOR = 3.57, 95% CI: 3.36-3.79). Inadequate PNC was associated with higher odds of PTB over time (effect modification p  < 0.0001). Inadequate PNC was associated with 5.4 times higher odds of PTB in 1998, 7.0 times in 2008, and 9.1 times in 2018., Conclusion:  Despite an increase in adequate PNC, there was a rise in PTB associated with inadequate and suboptimal PNC. PNC utilization was a stronger risk factor in recent years with higher PTB in patients who attended more than five PNC visits., Key Points: · PNC utilization is associated with the risk of PTB.. · Despite an increase in PNC utilization, PTB rates have increased.. · There is an even stronger association between PNC utilization and PTB over time.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Inefficient supply chain management within the US healthcare industry results in significant financial and environmental impact. Unopened medical supplies may routinely be discarded in the Emergency Department (ED), contributing as a source of unnecessary medical waste., Objectives: Quantify the financial and environmental impact of unopened medical supplies that are routinely discarded in two EDs., Methods: The study utilized a waste audit of collection bins targeting unopened medical supplies that would have otherwise been discarded. Associated financial cost was calculated using data from the purchasing department and from an online search. End-of-life (EOL) environmental impact was calculated using the M+ Wastecare calculator. A lifecycle analysis was performed on a supplier-packaged intubation kit, which the study identified as a significant source of waste., Results: High volumes of unused, unopened supplies (143.48 kg) were collected during the study period with a yearly extrapolated value of 1337 kg. Purchasing costs over 44 days at Hospital A and 37 days at Hospital B for these items amounted to $16,159.71 across both sites with a yearly extrapolated value of $150,631.73. Yearly extrapolated EOL impact yielded 5.79 tons per year of CO2eq. Components from supplier-packaged intubation kits were found to contribute to 45.2% of collected items at one site which purchased them. Lifecycle analysis of an intubation kit yields 23.6 kg of CO2eq., Conclusion: This study demonstrates that the disposal of unopened medical supplies contributes a significant source of financial and environmental waste in the ED setting. The results continue to support the trend of procedure kits generating significant environmental and financial waste., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Military transport can induce whole-body vibrations, and combat almost always involves high impact between lower extremities and the ground. Therefore, robust splinting technology is necessary for lower extremity fractures in these settings. Our team compared a novel one-step spray-on foam splint (FastCast) to the current military standard structured aluminum malleable (SAM) splint., Materials and Methods: Ten cadaveric specimens were subjected to complete tibia/fibula osteotomy. Specimens were fitted with custom accelerometer and gyroscope sensors superior and inferior to the fracture line. Each specimen underwent fracture and splinting from a standard of care SAM splint and an experimental FastCast spray foam splint in a randomized order. Each specimen was manually transported to an ambulance and then released from a 1 meter height to simulate impact. The custom sensors recorded accelerations and rotations throughout each event. Repeated-measures Friedman tests were used to assess differences between splint method within each event and between sensors within each splint method., Results: During splinting, overall summation of change and difference of change between sensors for accelerations and rotations were greater for SAM splints than FastCast across all axes (P ≤ 0.03). During transport, the range of acceleration along the linear superior/inferior axis was greater for SAM splint than FastCast (P = 0.02), as was the range of rotation along the transverse plane (P < 0.01). On impact, the summation of change observed was greater for SAM splint than FastCast with respect to acceleration and rotation on the posterior/anterior and superior/inferior axes (P ≤ 0.03), and the cumulative difference between superior and inferior sensors was greater for SAM than FastCast with respect to anterior-axis rotation (P < 0.05)., Conclusion: FastCast maintains stabilization of fractured lower extremities during transport and impacts to a significantly greater extent than SAM splints. Therefore, FastCast can potentially reduce the risk of fracture complications following physical stressors associated with combat and extraction., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Acute brain injuries are caused by a variety of etiologies, each potentially disrupting neurological function. The neurologic impairments are on a spectrum of severity often creating functional barriers to completing activities of daily living. Initial treatment starts immediately upon diagnosis and requires a multimodal approach working to prevent systemic changes. Therapy, bracing treatment, injections, and pharmacologic treatments are the mainstay of early intervention. Worsening upper motor neurological impairment associated with involuntary muscle hyperactivity can lead to a spastic equinovarus foot deformity. Spastic equinovarus foot deformities secondary to anoxic brain injuries or traumatic brain injury pose a challenging situation for orthopaedic surgeons because of associated cognitive impairment, spastic tone, and extensive soft-tissue contractures prohibiting bracing treatment. Tendon releases and transfers in combination with functional bracing treatment are initially attempted, and selective fusions are performed for severe cases. Surgical indications are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Contemporary, multidisciplinary research sheds light on data privacy implications of artificial intelligence (AI). This review adopts an AI ecosystem perspective and proposes a process-outcome continuum to classify AI technologies; this perspective helps to understand the nuances of AI relative to psychological aspects of privacy decision-making. Specifically, different types of AI affect traditionally studied privacy decision-making frameworks including the privacy calculus, psychological ownership, and social influence in varied ways. By understanding how the process- or outcome-orientation of an AI technology affects privacy decision-making, we explain how AI creates privacy benefits but also poses challenges. Future research is needed across privacy decision-making, but also more generally at the intersection of privacy and AI, to help foster an ethical, sustainable society., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective To evaluate the variation in the area estimation under different mathematical calculations against measurement by a smartphone application in estimating the cutaneous wound areas in captive Asian elephants. Methods The study was conducted on captive Asian elephants (Elephas maximus) with cutaneous wounds reported to Veterinary Hospitals of Kerala Veterinary and Animal Sciences University and elephant camps within and outside Kerala state (mostly southern states of India, namely, Kerala and Tamil Nadu) over the period September 2019 to October 2022. Thirty-five clinical cases diagnosed with skin wounds of different aetiologies at various parts of the body were subjected to measurement, and 111 measurements were taken using a smartphone application, Imito Measure (Imito AG, Zurich, Switzerland). Based on the outer wound perimeters hand-marked on the mobile screen over the image taken, Imito Measure calculated the length, width, perimeter, and area. The length and width measurements from this were applied to four mathematical models of wound measurements. Wound surface area calculations were further done by these models and were compared. Results The observed results indicated no significant difference between the five methods of area measurement in all the studied cases since the P > 0.05. Conclusion The findings revealed no significant difference between the five techniques of wound area measurement. From the practical clinical utility point, the smartphone application has an edge over the mathematical methods in animals, especially captive Asian elephants, as it has the major advantage of being non-contact and thus addresses some major welfare concerns., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: Kerala Veterinary and Animal Sciences University Issued protocol number XIIIth FRC. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Giggin et al.)

Objective: To evaluate the h- and m-indices of academic urologists across all U.S. accredited urology residency programs to determine the relationship between these metrics and an author's academic rank, academic degrees, and gender., Methods: A total of 136 urology residency programs with available faculty information on their websites were evaluated. The academic rank, academic degrees, and gender were recorded for each clinical and research faculty member. Each author's h-index was determined using the Scopus database. The m-indices for each author were then calculated. Statistical analysis was performed using the Wilcoxon rank-sum test., Results: This study demonstrated that the h- and m-indices positively correlate with an author's academic rank. Among the 2253 academic urologists evaluated, chairs/chiefs and professors had the highest median h- and m-indices (h-index 26, m-index 1.046 for chairs/chiefs; h-index 30, m-index 1.094 for professors). This was followed by associate professors (h-index 14, m-index 0.750), assistant professors (h-index 6, m-index 0.667), and clinical instructors (h-index 6, m-index 0.511). The median h- and m-indices were overall statistically higher for males than females. Faculty members with only a PhD were found to have the highest h- and m-indices followed by MD PhD, MD MBA, MD MPH, MD only, and DO only in descending order of index value., Conclusion: The h- and m-indices of academic urologists positively correlate with their academic rank. These metrics may serve as an additional tool in measuring an individual's academic productivity in consideration of job hirings, positional promotions, societal memberships, achievement awards, research grants, and more., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Lateral ankle sprains are the most common type of injury to the ankle and can lead to ankle instability. There are many described techniques for the surgical treatment of lateral ankle instability. The purpose of this study is to quantify the variation in surgeon technique for lateral ankle instability treatment., Methods: Surveys were sent to 62 orthopaedic foot and ankle surgeons regarding surgical technique for the treatment of lateral ankle instability. Clinical agreement was defined as greater than 80% agreement to assess the cohesiveness of surgical methods as described by Marx et al. Results. Response rate was 49/62 (79%). There was clinical agreement for not using bone tunnels and not using metal anchors. All other factors lacked clinical agreement. A greater average number of throws and knots (4.2 for each, range 1-6 throws, range 2-12 knots) were used by surgeons that do not believe knots cause pain compared to an average of 3.9 (range, 1-6) throws and 4.0 (range, 2-15) knots by surgeons who do believe knots cause pain. The association that surgeon who believed knots do cause pain and thus used fewer knots and throws was not statistically significant (P > .05). The preferred material by surgeons in our study are as follows: nonabsorbable braided suture (26/49, 53%), suture tape (15/49, 31%), and fiber tape (4/49, 8%). Among surgeons who use absorbable suture (34/49, 69%), there was no significant difference (P > .05) between surgeons who believe knots cause pain (23/34, 68%) and those who do not (11/34, 32%)., Discussion and Conclusion: Among this small sample of orthopaedic foot and ankle surgeons, there is wide variation in surgical technique for lateral ankle instability treatment and little agreement on the clinical standard of care. This disagreement highlights the need for comparative outcome studies in the treatment of ankle instability., Level of Evidence: Level III: Retrospective cohort study ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In 2018, the tuberculosis molecular bacterial load assay (TB-MBLA), a ribosomal RNA-based test, was acknowledged by WHO as a molecular assay that could replace smear microscopy and culture for monitoring tuberculosis treatment response. In this study, we evaluated the accuracy of TB-MBLA for diagnosis and monitoring of treatment response in comparison with standard-of-care tests., Methods: For this longitudinal prospective study, patients aged 18 years or older with presumptive tuberculosis (coughing for at least 2 weeks, night sweats, and weight loss) were enrolled at China-Uganda Friendship Hospital Naguru (Kampala, Uganda). Participants were evaluated for tuberculosis by TB-MBLA in comparison with Xpert MTB/RIF Ultra (Xpert-Ultra) and smear microscopy, with Mycobacteria Growth Indicator Tube (MGIT) culture as a reference test. Participants who were positive on Xpert-Ultra were enrolled on a standard 6-month anti-tuberculosis regimen, and monitored for treatment response at weeks 2, 8, 17, and 26 after initiation of treatment and then 3 months after treatment., Findings: Between Nov 15, 2019, and June 15, 2022, 210 participants (median age 35 years [IQR 27-44]) were enrolled. 135 (64%) participants were male and 72 (34%) were HIV positive. The pretreatment diagnostic sensitivities of TB-MBLA and Xpert-Ultra were similar (both 99% [95% CI 95-100]) but the specificity was higher for TB-MBLA (90% [83-96]) than for Xpert-Ultra (78% [68-86]). Ten participants were Xpert-Ultra trace positive, eight (80%) of whom were negative by TB-MBLA and MGIT culture. Smear microscopy had lower diagnostic sensitivity (75% [65-83]) but higher specificity (98% [93-100]) than TB-MBLA and Xpert-Ultra. Among participants who were smear microscopy negative, the sensitivity of TB-MBLA was 96% (95 CI 80-100) and was 100% (95% CI 86-100) in those who were HIV positive. 129 (61%) participants were identified as tuberculosis positive by Xpert-Ultra and these individuals were enrolled in the treatment group and monitored for treatment response. According to TB-MBLA, 19 of these patients cleared bacillary load to zero by week 2 of treatment and remained negative throughout the 6-month treatment follow-up. Positivity for tuberculosis decreased with treatment as measured by all tests, but the rate was slower with Xpert-Ultra. Consequently, 31 (33%) of 95 participants were still Xpert-Ultra positive at the end of treatment but were clinically well and negative on TB-MBLA and culture at 6 months of treatment. Two patients were still Xpert-Ultra positive with a further 3 months of post-treatment follow-up. The rate of conversion to negative of the DNA-based Xpert-Ultra was 3·3-times slower than that of the rRNA-based TB-MBLA. Consequently for the same patient, it would take 13 weeks and 52 weeks to reach complete tuberculosis negativity by TB-MBLA and Xpert-Ultra, respectively. Participants who were positive on smear microscopy at 8 weeks, who received an extra month of intensive treatment, had a similar TB-MBLA-measured bacillary load at 8 weeks to those who were smear microscopy negative., Interpretation: TB-MBLA has a similar performance to Xpert-Ultra for pretreatment diagnosis of tuberculosis, but is more accurate at detecting and characterising the response to treatment than Xpert-Ultra and standard-of-care smear microscopy., Funding: European and Developing Countries Clinical Trials Partnership, Makerere University Research and Innovation Fund, US National Institutes of Health., Competing Interests: Declaration of interests WSa and SHG provide pro bono advice for LifeArc, a company that is developing TB-MBLA for clinical use. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Chronic Achilles tendon defects are commonly associated with substantial impairment in gait and push-off strength, leading to decreased function 1 . These injuries cause a unique surgical dilemma, with no consensus surgical reconstruction technique for >6-cm gaps 3 . There are a multitude of surgical reconstruction techniques that rely on gap size as a determinant for preoperative planning 1,2 . The present article describes a technique for chronic Achilles tendon defects of >6 cm. The central third fascia slide (CTFS) technique with flexor hallucis longus (FHL) transfer provides adequate excursion and strength while avoiding use of allograft. 2 .The CTFS technique is a reconstructive technique that is utilized to treat large chronically gapped Achilles tendon tears, usually larger than 5 to 6 cm; however, recent literature has shown that intermediate gaps can be fixed with use of a combination of tendon transfers. The technique described here is a variation of the V-Y tendinoplasty and fascia turndown method in which the gastrocnemius complex fascia is slid down rather than being "turned down." This reconstructive technique, like its predecessor, restores function in damaged Achilles tendons 3 . Chronic gapping from a chronic Achilles tendon rupture can lead to decreased function and weakness. Patients may also experience fatigue and gait imbalance, leading to the need for surgical reconstruction to help restore functionality., Description: The CTFS technique utilizes a posterior midline incision, maintaining full-thickness flaps. A complete debridement of the degenerative Achilles tendon is performed, and the gap is measured. If the gap is >6 cm, the central third of the remaining Achilles and gastrocnemius fascia are sharply harvested. The FHL is transferred to the proximal Achilles footprint and held with use of an interference screw. The ankle is held in 15° to 25° of plantar flexion while the FHL shuttling suture is pulled plantarly and secured with a bio-interference screw. The fascial graft is then anchored to the calcaneus with use of a double-row knotless technique, maximizing osseous contact potential healing. Soft-tissue clamps are placed on the graft and on the gastrocnemius complex harvest site. The ankle is tensioned in nearly 30° of plantar flexion to account for known postoperative elongation. FiberWire (Arthrex) is utilized to secure the tension, then the remaining suture tape from the proximal insertional row is run up each side of the fascial graft in a running locking stitch, continuing proximally to close the harvest site. The use of an anchor-stay stitch helps to prevent elongation and maximizes construct strength., Alternatives: For patients who are poor surgical candidates or those with acceptable function, alternatives include nonoperative treatment and/or the use of a molded ankle foot orthosis. Most chronic Achilles tendon ruptures require surgery. Generally, a gap of <2 cm can be treated through primary repair with use of longitudinal and distally applied traction. For an Achilles gap of >2 cm but <6 cm, a V-Y gastrocnemius-lengthening procedure can utilized. Other methods such as autologous and local tendon transfers, advancement procedures, or a combination of these have been described as ways to treat gaps within this range. For gaps of >6 cm, there is insufficient literature to establish a single gold-standard reconstructive technique. Some surgeons have opted to utilize the turndown flap procedure, the FHL tendon transfer technique, or a combination of both., Rationale: The Achilles turndown flap technique can lead to the formation of scar tissue at the focal point of the turndown, a region also known as the hinge joint, and thus can perpetuate scarring of the repair site. To avoid this scarring, the central third fascia slide technique with FHL transfer is presented as a suitable reconstructive technique for chronic tendon defects of >6 cm., Expected Outcomes: Postoperatively, patients are managed according to a standard protocol. The first 2 weeks are non-weight-bearing with the foot in equinus in an L & U splint. At 2 to 4 weeks postoperatively, a walking boot with a 1.5-cm heel lift is applied, and crutches are utilized as the primary weight-bearing aid. At 4 to 6 weeks, the patient is transitioned to a 1-cm heel lift and may discontinue the use of crutches if they are able to walk without a limp. At 8 weeks, the patient may discontinue the use of the walking boot. At week 6 to 12, no heel lift is required. By approximately 12 weeks postoperatively, the patient should have regained full range of motion and should be able to walk without a limp. The patient should be able to resume activities of daily living by 3 to 4 months, with a gradual return to all physical activities by 4 to 6 months This postoperative protocol has produced favorable results. Ahmad et al. have reported the use of a similar protocol, with patients showing increased Foot and Ankle Ability Measure scores and decreased visual analog scale pain scores compared with the preoperative measurement 2 ., Important Tips: Debride the Achilles until viable tendon is reached, then measure the defect.Tension the FHL and the fascia slide with the foot in 15° to 25° of plantar flexion.Perform a meticulous layered closure, preserving the paratenon as much as possible.Incomplete debridement may result in incompetent tissue.Incomplete closure of the fascia harvest site may predispose to seroma or hematoma formation.Not splinting for 10 to 14 days potentially predisposes the patient to wound breakdown., Acronyms and Abbreviations: CTFS = central third fascia slideFHL = flexor hallucis longusATTF = Achilles tendon turndown flapHPI = history of present illnessNWB = non-weight-bearingCAM = controlled ankle motionDVT = deep vein thrombosisMRI = Magnetic resonance imagingPMHx = past medical historyHTN = hypertensionSHx = social historyPE = physical examinationDF = dorsiflexionNVI = neurovascularly intactROM = range of motion., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A431)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Life expectancy in low- and middle-income countries (LMIC) continues to rise, resulting in a growing geriatric population. In Rwanda, a sub-Saharan LMIC, traumatic injuries are a common cause of mortality and morbidity. However, little is known about the frequency and type of traumatic injuries among geriatric populations in Rwanda., Objective: We explored the epidemiology and outcomes of trauma for geriatric patients presenting to the emergency department (ED) of the center Hospitalier Universitaire de Kigali (CHUK) in Rwanda., Methods: This prospective cross-sectional study was conducted from July 2019 to January 2020 at the ED of CHUK. Trauma patients aged 65 and above and alive at the time of evaluation were eligible for inclusion. Demographic characteristics were collected along with triage category, mechanism of injury, transfer status, transport method to CHUK, time spent at the ED, complications, and mortality predictors., Results: For the 100 patients enrolled, the most common injury mechanism was falls (63%), followed by road traffic accidents (28%). The majority of patients spent less than 48 h in the ED (63%). The mortality rate was 14%, with most deaths resulting from injury-related complications. Triage category, Kampala Trauma Score, and Glasgow Coma Scale were significant predictors of mortality, with p-values of 0.002, <0.001, and <0.001, respectively., Conclusions: The epidemiology of geriatric trauma found in this study can inform public health and clinical guidelines. Interventions targeting falls and road traffic accidents would target the most common geriatric trauma mechanisms, and clinical protocols that take into account predictors of mortality could improve outcomes and increase life expectancy for this population., Competing Interests: The authors declared no conflicts of interest., (© 2023 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Neurologic foot contractures pose a challenging situation for orthopaedic surgeons. These deformities are long-standing problems for patients with acute brain injuries, ultimately affecting their quality of life. We report our experience with using arthroscopic assisted, minimally invasive contracture tenotomies paired with a tibio-talo-calcaneal arthrodesis to achieve improved alignment and functional reconstruction of spastic equinovarus foot deformities., (© 2023 The Authors.)

More than 30,000 ankle sprains occur each day in the United States, and the majority of ankle sprains involve the anterior talofibular ligament. Up to 30% of patients develop functional ankle instability and chronic pain after a severe ankle sprain. When nonoperative measures are unsuccessful, operative reconstruction of the lateral ankle ligaments is recommended. To further strengthen the repair, accelerate rehabilitation, and allow for a quicker return to sport, augmentation with suture tape has recently become an alternative among surgeons in the reconstruction of the lateral ankle ligaments. Moreover, the advent of knotless all-suture anchors decreases the number of knots required in the procedure and, in theory, reduces lateral soft tissue irritation and accentuates recovery after surgery. Here we present our technique for arthroscopic assisted, lateral ligament reconstruction with suture tape augmentation and knotless all suture anchors., (© 2023 The Authors.)

Treatment of osteochondral lesions of the talus proves to be challenging given the unique anatomy of the intra-articular surface and associated complexity of larger lesions. Simple bone marrow-stimulating procedures for large complex lesions often lead to poor results with increased risk of lesion progression, refractory pain, and associated functional limitations. Other methods of osteochondral autografts or allografts often require osteotomies, bone windows, or fibrin glue, which are associated with donor pain and nonunion. Thus, for larger and cystic lesions, we report our experience using a modified low-flow arthroscopic sandwich technique consisting of autologous cancellous bone graft, followed by a viable cryopreserved cartilage fiber, cartilage allograft matrix putty., (© 2023 The Authors.)

Introduction: Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine., Methods: This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient., Results: Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01)., Conclusion: The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Treatment of seriously ill patients is often complicated by prolonged or complex transfers between hospitals in sub-Saharan Africa. Difficulties or inefficiency in these transfers can lead to poor outcomes for patients. "On-call" triage systems have been utilized to facilitate communication between facilities and to avoid poor outcomes associated with patient transfer. This study attempts to examine the effects of a pilot study to implement such a system in Rwanda., Methods: Data collection occurred prospectively in two stages, pre-intervention and intervention, in the emergency department (ED) at Kigali University Teaching Hospital (CHUK). All patients transferred during the pre-determined timeframe were enrolled. Data were collected by ED research staff via a standardized form. Statistical analysis was performed using STATA version 15.0. Differences in characteristics were assessed using χ 2 or Fisher's exact tests for categorical variables and independent sample t-tests for normally distributed continuous variables., Results: During the "on call" physician intervention, the indication for transfer was significantly more likely to be for critical care (P <.001), transfer times were faster (P <.001), patients were more likely to be displaying emergency signs (P <.001), and vital signs were more likely to be collected prior to transport (P <.001) when compared to the pre-interventional phase., Conclusion: The "[Emergency Medicine] EM Doc On Call" intervention was associated with improved timely interhospital transfer and clinical documentation in Rwanda. While these data are not definitive due to multiple limitations, it is extremely promising and worthy of further study.

Objectives: International trials have reported conflicting findings on whether the association between age and worse overall survival (OS) among children with Wilms tumor (WT) is due to age as an independent prognostic factor or the observation of more advanced disease at older ages. We sought to further elucidate this relationship using a population-based registry analysis., Methods: The Surveillance, Epidemiology, and End Results database was queried for all patients diagnosed with WT under the age of 20. The association between age and OS was assessed using multivariable Cox proportional hazards regression., Results: In this study, 3463 patients (54% female) were diagnosed with WT between 1975 and 2016. More advanced stage, larger primary tumor size, lymph node involvement, disease requiring radiotherapy, and omission of surgery were associated with worse OS ( P <0.05). More advanced stage, larger primary tumor size, and disease requiring radiotherapy were also associated with older age, whereas bilateral disease was associated with younger age ( P <0.001). On average, each year of age conferred an incremental hazard ratio (HR) of 1.07 (95% CI, 1.01 to 1.12, P =0.018) independent of relevant covariates. The rise in adjusted OS HR was most pronounced after the transitions in diagnosis age from 2 to 3 (HR age 3-15 vs. 0-2 1.77, 95% CI, 1.11 to 2.82, P =0.016) and from 15 to 16 (HR age 16-19 vs. 3-15 2.58, 95% CI, 1.06 to 6.25, P =0.036)., Conclusions: Diagnosis of pediatric WT at an older age was found to be independently associated with worse OS. Although additional prospective studies are warranted to examine tumor biology and other potential correlates, more aggressive treatment of older children based on age, especially as they approach early adulthood, may be considered in the multidisciplinary management of WT., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Great toe metatarsophalangeal joint (MTPJ) arthroscopy has been described in the literature for more than 50 years for treatment of a multitude of first MTPJ pathologies, including hallux rigidus, hallux valgus, and osteochondritis dissecans, among others. Despite this, the use of great toe MTPJ arthroscopy has not become widely used for treatment of these conditions as the result of reported difficulties with adequate visualization of the joint surface and manipulation of surrounding soft-tissue structures with the instruments available. We propose a simple technique with illustrations of the operating room setup and procedural steps to perform a dorsal cheilectomy in those with early-stage hallux rigidus using great toe MTPJ arthroscopy and a minimally invasive surgical burr in a way that is reproducible by foot and ankle surgeons., (© 2023 The Authors.)

Introduction: The Motricity Index (MI) can predict motor function after rehabilitation, but its minimal clinically important difference (MCID) has not been established. The primary study aim was to estimate the MCID value of the MI arm score., Methods: Between 2017 and 2018, 173 participants hospitalized with confirmed ischemic stroke were recruited into an observational rehabilitation study. Participants with motor weakness as measured by the Fugl-Meyer upper-extremity (FM-UE) and MI with complete baseline and follow-up assessments at 3 months were included in this analysis. The longitudinal recovery of the MI arm score was anchored to having a poor outcome based on the FM-UE recovery (<9) longitudinally. Results reported include the area-under-curve (AUC), along with sensitivity, specificity, and optimal cut-points based on maximizing the Youden statistic., Results: Sixty-nine patients (median [IQR] age 70 [18] years; 48% male; 54% white) were included in the final analysis. Mean ± standard deviation outcome scores at 3-months were: MI arm: 83.19 ± 22.80; FM-UE: 53.04 ± 17.26. For the primary results, the MI arm score optimal MCID cutoff for observed recovery was 13 points with a sensitivity of 80% (95% Confidence Interval (CI)(67.6%, 92.4%)) and a specificity of 69.0% (95% CI (52.1, 85.8%)), and the AUC was 0.8082 (0.7007, 0.9157)., Conclusions: This was the first study to report the MCID of the MI arm score, as anchored to the FM-UE recovery between acute evaluation and 3-months. The estimated optimal MCID of improvement in the MI arm score was 13 points.

Background: This closed reduction and percutaneous fixation (CRPF) technique utilizing suspensory fixation is indicated for the treatment of Lisfranc injuries with displacement or instability of the tarsometatarsal joint complex-and typically only for low-energy, purely ligamentous Lisfranc injuries. The goal of this procedure is to restore joint stability and prevent common complications of Lisfranc injuries (e.g., midfoot arch collapse and posttraumatic arthritis) while avoiding the complications and risks associated with open reduction and internal fixation (ORIF) and primary arthrodesis. We recommend performing the procedure within 10 to 14 days of the injury; otherwise, an open debridement may be necessary to address scar tissue formation., Description: We start with the patient in the supine position and perform a fluoroscopic stress examination of the joint. Next, the Lisfranc joint undergoes closed reduction, which is held in place with a clamp. Following reduction, a guidewire is drilled from the lateral border of the base of the 2nd metatarsal medially through the medial cuneiform, followed by a medial-to-lateral cannulated drill. The suspensory fixation is then passed lateral-to-medial, placing the suture button on the lateral cortex of the 2nd metatarsal base. The tape is then tensioned while a bioabsorbable interference screw is inserted to maintain tension., Alternatives: Prior studies have assessed both operative and nonoperative alternatives to CRPF with suspensory fixation for the treatment of Lisfranc injuries. Nonoperative treatment with closed reduction and cast immobilization of Lisfranc injuries is typically reserved for nondisplaced injuries; however, a number of studies have shown poor outcomes with use of this technique 1-3 . The 2 most common operative alternatives are ORIF and primary arthrodesis 4 ., Rationale: CRPF with suspensory fixation offers several benefits over both traditional surgical techniques such as ORIF and primary arthrodesis, as well as over percutaneous reduction and internal fixation (PRIF) with a screw. Compared with ORIF and primary arthrodesis, a number of studies have shown that percutaneous treatment of Lisfranc injuries minimizes soft-tissue trauma and reduces the risk of postoperative complications such as wound breakdown, infection, and complex regional pain syndrome, while allowing for earlier participation in rehabilitation 5-10 . A systematic review of outcomes following PRIF with screw fixation also showed that percutaneous treatment of Lisfranc injuries is a safe and effective technique with good functional outcomes 11 . When comparing PRIF with a screw to our technique of CRPF with suspensory fixation, CRPF has the added benefit of creating a nonrigid fixation in the Lisfranc joint, which allows for increased range of motion of the medial column and improved return to activity 12,13 . The rigid fixation in PRIF with a screw can also lead to metal irritation, intra-articular screw fracture, and impaired mobility, which often necessitate the need for screw removal 13-15 . This fixation-related drawback is not present with our technique, and also avoids the need for use of a biologic substitute such as tendon grafts 13 ., Expected Outcomes: Following CRPF with suspensory fixation, patients can expect to return to full activity at 12 to 16 weeks postoperatively. Postoperatively, patients are typically kept non-weight-bearing for 6 weeks. The operative foot is kept immobilized in a splint for the first 2 weeks, then transitioned to a boot. Between postoperative weeks 6 and 12, partial progressive weight-bearing is introduced with use of an arch support, progressing toward full weight-bearing 13,16,17 .For comparison, patients who underwent PRIF with screw fixation had a similar postoperative course, but almost all required screw removal at 4 to 6 months postoperatively 13,16 . Cho et al. retrospectively reviewed the results of 63 patients who underwent either PRIF with screw fixation (n = 32) or CRPF with a suture button (n = 31) and found that CRPF patients had significantly better American Orthopaedic Foot & Ankle Society midfoot scale scores (81 versus 74 points) and visual analog scale scores (3.1 versus 4.6 points) at 6 months postoperatively and prior to screw removal in the PRIF group (p < 0.001). There were no significant differences in these scores, radiographic outcomes, weight-bearing analysis, or complications at 1 year postoperatively. The authors concluded that both techniques provided comparable fixation stability and clinical outcomes. Of note, however, the PRIF group had 4 patients whose postoperative course was complicated by screw breakage 13 ., Important Tips: Start with a fluoroscopic stress examination to identify all components of instability.Ensure that the reduction clamp does not interfere with or affect your guidewire path.If the joint cannot be reduced, convert to an open procedure and debride the obstruction., Acronyms and Abbreviations: ORIF = open reduction and internal fixationPRIF = percutaneous reduction and internal fixationCRPF = closed reduction and percutaneous fixationNSAID = nonsteroidal anti-inflammatory drugOR = operating roomAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingAOFAS = American Orthopaedic Foot & Ankle SocietyVAS = visual analog scaleROM = range of motionPT = physical therapyASA = acetyl-salicylic acid (aspirin)BID = twice dailyPRN = as needed., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A403)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

This study measured implicit and explicit racial bias about women and handguns and addressed important perceptions and stereotypes about gun competence and victimization that vary based on race and gender. We administered a national survey to 1,000 US adults using a new Race-Women-Handguns Implicit Association Test (IAT). Survey weighting was used to generate nationally representative estimates on the prevalence of implicit racial bias about women with handguns. The majority of participants (62.5%) associated Black women with handguns and White women with smartphones (weighted-mean IAT = 0.252; 95% CI [0.227, 0.276]) reflecting an anti-Black bias among US adults that is stereotype consistent associating Black women with handguns and White women with smartphones. The proportion that indicated Black and White women were competent with handguns was low (21.6% and 22.4%, respectively), and the proportion of US adults who indicated Black women are more likely to experience intimate partner violence (range: 19.4%-22.9%) and sexual harassment/assault (range: 11.4%-20.4%) was low compared to the prevalence of both forms of violence US among Black women that may impact the decision to possess a handgun. These findings suggest there is an anti-Black implicit bias about women with handguns (associating Black women with handguns) among US adults and support the need for further research measuring racism in systems and structures that intersect with gun possession.