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The recent rise of active shootings calls for adequate preparation. Currently, the "Run, Hide, Fight" concept is widely accepted and adopted by many hospitals nationwide. Unfortunately, the appropriateness of this concept in hospitals is uncertain due to lack of data. To understand the "Run, Hide, Fight" concept application in hospitals, a review of currently available data is needed. A systematic review was done focusing on the "Run, Hide, Fight" concept using multiple databases from the past 12 years. The PRISMA flow diagram was used to systematically select the articles based on specific inclusion and exclusion criteria. The measurements were subjective evaluations and survival probabilities post-concept. One agent-based modeling study suggested a high survival probability in non-medical settings. However, there is a paucity of data supporting its effectiveness and applicability in hospitals. Literature suggests a better suitable concept, the "Secure, Preserve, Fight" concept, as a response protocol to active shootings in hospitals. The effectiveness of the "Run, Hide, Fight" concept in hospitals is questionable. The "Secure, Preserve, Fight" concept was found to be designed more specifically for hospitals and closes the gaps on the flaws in the "Run, Hide, Fight" concept.

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BACKGROUND AND OBJECTIVES: Patients with intracranial gunshot wounds (IC-GSWs) often present with severe neurological injuries requiring prompt neurological evaluation. Neurosurgical intervention is reserved for those with reasonable chances of survival. Handguns and long guns, such as shotguns and rifles, have differing mechanisms of injury which may influence surgical candidacy and outcomes. This study aims to compare rates and types of neurosurgical intervention and inpatient outcomes in patients with IC-GSWs handguns and long guns. METHODS: The National Trauma Data Bank was retrospectively queried for patients with IC-GSWs from 2017 to 2019. Patients with long gun IC-GSWs were propensity score matched with those with handgun IC-GSWs based on patient demographics, comorbidities, insurance status, injury extent and severity, and hospital trauma level. Group differences were compared using Student's t-tests and Pearson's χ2 tests, and multivariable logistic regression was used to identify predictors of in-hospital mortality. RESULTS: Overall, patients in the long gun group were more likely to undergo neurosurgical intervention (21% vs 17%, P = .02). Following propensity score matching, the long gun group had lower rates of in-hospital mortality (35% vs 43%, P < .01), lower rates of cardiac arrest (5% vs 8%, P = .02), and lower rates of reoperation (0% vs 2%, P = .02) than the handgun group. In multivariable regression, independent predictors of survival included long gun IC-GSWs (odds ratio [OR] 0.65, CI 0.52-0.83), neurosurgical foreign body removal (OR 0.44, CI 0.33-0.58), intracranial debridement (OR 0.47, 0.33-0.67), and craniectomy (OR 0.46, CI 0.34-0.63). CONCLUSION: Patients with IC-GSWs present to the hospital with severe neurological injury. Neurosurgical intervention was independently associated with decreased mortality. After matching, patients with long gun IC-GSWs experienced lower in-hospital mortality rates compared with those from handguns. This study suggests that patients suffering from long gun IC-GSW may respond particularly well to neurosurgical intervention and firearm type should be considered when determining neurosurgical candidacy.

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OBJECTIVE: Aim: To explore the capabilities of the modern 3D modeling method for various elements of gunshot wounds caused by 9 mm caliber bullets, intending to integrate these findings into the theory and practice of forensic medicine. PATIENTS AND METHODS: Materials and Methods: The research began with a series of experimental shots, during which the morphological features were examined through their 3D spatial reconstruction. The entire series of experimental shots was conducted using an automatic pistol IZH 70-01 equipped with 9.0 mm caliber bullets. The ballistic clay Roma Plastilina No.1, manufactured in the USA, was utilized as a material for conducting standard ballistic tests according to the standards of the NIJ (National Institute of Justice) and HOSDB (Home Office Scientific Development Branch). RESULTS: Results: The research was continued during the performance of forensic examinations involving actual cases of gunshot injuries. The dimensions of individual elements of the wound channel were measured in both experimental and expert cases using conventional measuring tools, as well as after their 3D modeling, utilizing graphic editors such as "Agisoft Photoscan" and "3ds max". CONCLUSION: Conclusions: In the course of creating and studying experimental and expert 3D models, the dimensions of individual morphological elements of the wound channel were recorded with an accuracy that exceeded the results obtained through measurements using traditional measurement methods by ten times.

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During the investigation of firearm-related incidents, gunshot residues (GSR) can be collected on the scene and individuals (e.g., shooters or bystanders). Their analysis can give valuable information for the reconstruction of the events. Since GSR collection on persons of interest generally occurs a few minutes to hours after discharge, knowledge is needed to understand how organic (O), and inorganic (I) residues are transferred and persist. In this research, the quantities of OGSR and IGSR were assessed on the right and left hands, forearms, face, and nostrils of four shooters. Specimens were collected immediately before the discharge (shooter's blank specimens) and shortly after (30 min) using carbon adhesive stubs. Organic compounds were first extracted from the collection device and analysed using ultra-high-performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS). Subsequently, IGSR particles were detected on the same stub using scanning electron microscopy coupled with energy-dispersive X-ray spectrometry (SEM/EDS). Shooter's blank specimen analysis revealed background contamination of both O and IGSR in the shooter's environment, predominantly attributed to the presence of an indoor shooting range. However, the background quantities generally remained below the associated 30-minute specimen. Thirty minutes after a discharge, higher quantities were generally detected on the shooter's right and left hands than on other collection regions for both GSR types. Forearms and face emerged as interesting collection alternatives, especially in cases where a person of interest may have washed their hands in the interval between the discharge and collection. In contrast, very low amounts of GSR were detected in the nostrils. Furthermore, the results indicated that OGSR and IGSR have different transfer and persistence mechanisms.

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More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool.

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Objectives. To assess differences in contextual factors by intent among pediatric firearm injury patients and determine factors associated with data missingness. Methods. We retrospectively queried the American College of Surgeons Firearm Study database (March 1, 2021-February 28, 2022) for patients aged 18 years or younger. We stratified preinjury, firearm-related, and event-related factors by intent and compared them by using Fisher exact, χ2, or 1-way analysis of variance testing. Secondary analysis estimated the adjusted odds of missingness by using generalized linear modeling with binominal logit link. Results. Among 17 395 patients, 2974 (17.1%) were aged 18 years or younger; 1966 (66.1%) were injured by assault, 579 (19.5%) unintentionally, and 76 (2.6%) by self-inflicted means. Most contextual factors differed by intent, including proportion of youths with previous adverse childhood experiences, mental illness, and violent assaults or injury, firearm type and access, perpetrator relationship, and injury location. In adjusted analyses, age, trauma center designation, intent, and admission status were associated with missingness. Conclusions. Contextual factors related to pediatric firearm injury vary by intent. Specific predictors associated with missingness may inform improved future data collection. Public Health Implications. Contextual factors related to pediatric firearm injury can be obtained in a systematic manner nationally to inform targeted interventions. (Am J Public Health. 2024;114(10):1097-1109. https://doi.org/10.2105/AJPH.2024.307754).

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This study estimates the association between Florida's red flag law enactment and firearm and nonfirearm homicide and suicide rates.

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INTRODUCTION: The purpose of this paper is to examine a scalable secure firearm storage intervention in the U.S. National Guard (NG) in preventing firearm injury and suicide. A study among firearm-owning members of the Mississippi NG testing Project Safe Guard (PSG), a 10 to 15 min lethal means counseling intervention, found that PSG increased self-reported secure firearm storage practices. Here, we sought to examine a "real world" rollout of a modified PSG program in the NG in which NG members were trained to understand the importance of lethal means safety and to deliver PSG to Guardsmen peers within their units. MATERIALS AND METHODS: The PSG team collaborated with the NG to identify 4 states for the rollout; for each state, the NG was responsible for identifying key personnel ("facilitators") who would receive the training. Team members provided in-person training at 5 locations across 4 states (AZ, GA, IA, and NV) from January to April 2023. Attendees were provided with combination trigger locks or cable locks and evaluation instructions. Questionnaires were administered to training attendees via REDCap at pre-training and post-training. We conducted descriptive and comparison statistics of questionnaire data. RESULTS: A total of 186 facilitators were trained at 5 in-person training locations across 4 states (AZ, GA, IA, and NV) from January to April 2023; data collection concluded in August 2023. There were 137 pre-training responses (74% pre-survey response rate) and 88 post-training responses (64% response rate from those who took the pre-training survey). Findings demonstrate increases in self-reported knowledge, attitudes, and beliefs regarding firearm injury and suicide and a reported desire to store personal firearms more securely. CONCLUSION: The adapted version of PSG shows promise as a relevant and acceptable intervention among Guardsmen to enhance knowledge and attitudes regarding firearm suicide, increase secure firearm storage practices, and normalize conversations about firearm suicide prevention among peers. This intervention seeks to frame firearm suicide prevention within a culture of safety, complementary to the existing prevention methods and training within the NG.

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Despite the early promise of centering structural racism in explanatory models of firearm violence, there are noticeable gaps in what's been produced thus far; in particular, a deeper and more serious engagement with long-standing theories of racism is needed to further enrich our understanding of how structural inequalities produce unequal burdens of firearm-related harms. Thus, building on theories and concepts from a range of academic fields and Black philosophical perspectives, we developed a theoretical framework to help explain the role of place-based structural racism on firearm violence disparities. A central component of our framework is the concept racial capitalism, which contends that racial exploitation and the accumulation of assets depend on and reinforce one another. In this article, we present our framework and highlight how two processes related to racial capitalism-racialized dispossession and racialized spatial stigma-are connected with geographic disparities in firearm violence. We also present the results of an ecological cross-sectional study that reveals a potential key association between racial capitalism and firearm violence disparities on the neighborhood-level. We used a structural intersectionality approach and descriptive epidemiological methods to highlight and quantitatively describe spatial firearm violence disparities that could potentially be linked to the varying exposure of two dimensions of racial capitalism-historical redlining and contemporary racialized subprime mortgage lending. We found that sustained disadvantaged census tracts (tracts that were historically redlined and experienced higher contemporary subprime lending) experienced the highest burden of firearm violence in Baltimore City between 2015 and 2019. Our research suggests that racial capitalism could potentially be a root cause of firearm violence disparities. A theoretical framework based on racial capitalism can inform the development and usage of indicators and analytic methods for racism-related firearm violence research. Moreover, this framework can identify factors to prioritize in equity-based violence prevention policies and programs.

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This article aims to analyze temporal trends in female firearm homicides in the Northeast of Brazil during the period 2000-2019. We conducted an ecological study using data on firearm homicides of women aged 10 years and over obtained from the Mortality Information System. The population data were taken from the 2010 Census. Homicide rates were calculated after correcting the data to account for differences in the quality and coverage of death records. Trends were assessed using negative binomial regression and described using relative risk and p values. Average annual percentage changes in homicide rates were also calculated. The regional firearm homicide rate during the study period was 4.40 per 100,000 women. Rates were highest in the state of Alagoas (5.40), the 15-19 age group (5.84) and in public thoroughfares (1.58). Trends were upward across all states except Pernambuco, where they were downward, and Alagoas, where rates were stationary. The place of occurrence with the highest percentage increase in firearm homicides over the study period was public thoroughfares. Female firearm homicides showed an upward trend across most northeastern states.

O objetivo deste artigo é analisar a tendência temporal dos homicídios femininos perpetrados por arma de fogo nos estados nordestinos, no período de 2000 a 2019. Estudo ecológico, com dados de homicídios por arma de fogo em mulheres com 10 ou mais anos, registrados no Sistema de Informação Sobre Mortalidade. Os dados de mortalidade e os dados populacionais foram obtidos junto ao Departamento de Informática do Sistema Único de Saúde. Após a correção dos registros de óbito para qualidade e cobertura dos óbitos, as taxas de mortalidade foram calculadas Tendências foram avaliadas por regressão binomial negativa, classificadas de acordo com o valor do risco relativo e valor de p. Calculou-se a variação percentual anual média das taxas de mortalidade. A região apresentou 4,40 homicídios por arma de fogo por 100 mil mulheres no período do estudo, maiores coeficientes em Alagoas (5,40), na faixa etária de 15-19 anos (5,84), e via pública (1,58). As tendências foram ascendentes, com exceção de Pernambuco em que foi descendente, e estacionárias em Alagoas. Os homicídios por arma de fogo em via pública apresentaram maior percentual de aumento no período estudado. Observou-se tendência ascendente nos homicídios femininos perpetrados por arma de fogo na maioria dos estados nordestinos.

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This paper presents a simulation modeling study that examines the potential benefit of arming public school staff members with concealed carry weapons (CCWs) in combination with school resource officers (SROs) during active shooter events. By simulating real or hypothetical situations and altering various parameters, simulation modeling allows researchers to explore the potential factors that may influence the outcome of such situations. This study will analyze literature on active shootings to identify key characteristics that may impact the outcome of an event and will use an actual school active shooter event as a basis for developing a simulation model. The researchers will then introduce a CCW carrier and an SRO into the scenario to assess the potential impact and outcomes of such a change. The results of this study may inform the development of effective policies and procedures for addressing active shooter events in public settings.

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The leading cause of death in children in the United States is injury caused by firearm violence. States that enact stricter laws related to firearm injury prevention have lower rates of mortality in children. In Illinois, we formed a coalition with medical professionals, medical organizations, community partners, and legislators to craft legislation to reduce the burden of firearm violence on children. These laws can be politically charged. Therefore, we decided to focus on a safe storage education law. We met regularly as a group to draft the bill and an information sheet to support it. Pediatricians and pediatric providers worked with the government relations teams in children's hospitals throughout the state to garner supporting organizations. We also worked to garner cosponsors, provided written and oral testimony to the legislative body, and wrote op-eds to support the bill. Shortly after the bill was passed and signed into law in June of 2022, there was a mass shooting at Highland Park in Illinois. After the shooting, there was a mandate from the Illinois governor to work on passing an assault weapons ban. Pediatricians again provided input into the bill about how the weapons affect children, testified before the House Judiciary Committee, and wrote op-eds. Governor Pritzker signed the Protect Illinois Communities Act into law in January of 2023. Pediatricians actively worked in the passage of both bills, which highlights the importance of medical professionals as experts who can combine powerful stories and evidence based medicine to influence policy.

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Importance: Causal associations between household firearm ownership rates (HFRs) and firearm mortality rates are not well understood. Objective: To assess the population-level temporal sequencing of firearm death rates and HFRs. Design, Setting, and Participants: This cohort study used autoregressive cross-lagged models to analyze HFRs, firearm suicide rates, and firearm homicide rates in the US from 1990 to 2018. The suicide analyses included 16 demographic subgroups of adults, defined by study year, state, sex, race and ethnicity, marital status, and urbanicity. The homicide analyses consisted of adult subgroups living in urban or rural areas. Data analysis was conducted from March to December 2023. Exposures: Firearm mortality rates and HFRs. Main Outcomes and Measures: Firearm homicide and suicide rates with HFRs as the exposure, and HFR with mortality as the exposure. Results: A total of 10 416 observations of 16 demographic subgroups by state and 2-year periods were included in the suicide analyses, while 1302 observations from 2 demographic subgroups by state and 2-year period were included in the homicide analysis. At baseline, the mean (SD) rate per 100 000 population across strata was 7.46 (7.21) for firearm suicides and 3.32 (2.13) for firearm homicides. The mean (SD) baseline HFR was 36.9% (20.2%) for firearm suicides and 36.9% (14.8%) for firearm homicides. Higher HFR preceded increases in suicide rates: demographic strata with equal firearm suicide rates but which differ by 18.6 percentage points on HFR (1 SD) would be expected to have firearm suicide rates that diverged by 0.19 (95% CI, 0.15-0.23) deaths per 100 000 population per period. With these differences accumulated over 8 years, firearm suicide rates in subgroups with the highest decile HFR would be expected to have 1.93 (95% CI, 1.64-2.36) more suicides per 100 000 population than strata with lowest decile HFR, a difference of 25.7% of the overall firearm suicide rate in 2018 and 2019. Firearm suicide rates had a smaller magnitude of association with subsequent changes in HFR: strata with equal HFRs but which differ by 1 SD in firearm suicide rates had minimal subsequent change in HFRs (-0.02 [95% CI, -0.04 to 0.01] percentage points). A 1-SD difference in HFRs was associated with little difference in next-period overall firearm homicides rates (0.03 [95% CI, -0.02 to 0.08] per 100 000 population), but a 1-SD difference in homicide rates was associated with a decrease in HFR (-0.09 [95% CI, -0.16 to -0.04] percentage points). Conclusions and Relevance: This cohort study found an association between high HFRs and subsequent increases in rates of firearm suicide. In contrast, higher firearm homicide rates preceded decreases in HFRs. By demonstrating the temporal sequencing of firearm ownership and mortality, this study may help to rule out some theories of why gun ownership and firearm mortality are associated at the population level.

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BACKGROUND: Annual global data on mental disorders prevalence and firearm death rates for 2000-2019, enables the U.S. to be compared with comparable counties for these metrics. METHODS: The Institute for Health Metrics and Evaluation (IHME) Global Health Burden data were used to compare the prevalence of mental disorders with overall, homicide and suicide firearm death rates including homicides and suicides, in high sociodemographic (SDI) countries. RESULTS: Overall and in none of the nine major categories of mental disorders did the U.S. have a statistically-significant higher rate than any of 40 other high SDI countries during 2019, the last year of available data. During the same year, the U.S. had a statistically-significant higher rate of all deaths, homicides, and suicides by firearm (all p<<0.001) than all other 40 high SDI countries. Suicides accounted for most of the firearm death rate differences between the U.S. and other high SDI countries, and yet the prevalence of mental health disorders associated with suicide were not significantly difference between the U.S. and other high SDI countries. CONCLUSION: Mental disorder prevalence in the U.S. is similar in all major categories to its 40 comparable sociodemographic countries, including mental health disorders primarily associated with suicide. It cannot therefore explain the country's strikingly higher firearm death rate, including suicide. Reducing firearm prevalence, which is correlated with the country's firearm death rate, is a logical solution that has been applied by other countries.

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Importance: A loophole in US gun policy is that people can purchase guns from private sellers without going through any background check. Some states have addressed this loophole by requiring universal background checks for all gun sales, either at the point of sale or through a permit system; however, most studies on the effectiveness of universal background checks have not analyzed these 2 policy mechanisms separately. Objective: To assess the association of point-of-sale background check law and gun permit law, separately, with firearm homicide rates from 1976 through 2022 using the same methods and model specification. Design, Setting, and Participants: This cross-sectional study used a difference-in-differences, fixed-effects regression model to evaluate firearm laws and firearm homicide rates in 48 states from 1976 through 2022. Data were obtained for 48 states except New Hampshire and Vermont and were analyzed in January 2024. Exposures: Implementation of either the law requiring a universal background check at point of sale for all firearms without a permit or the laws combining universal background checks and a state permit requirement for all gun purchasers. Main Outcomes and Measures: Annual, state-specific rates of firearm homicide per 100 000 people. Results: From 1976 through 2022, 12 states adopted the universal background check laws without permitting requirements and 7 states implemented gun permit laws covering all firearms. The mean (SD) firearm homicide rate was 4.3 (0.1) per 100 000 people. Universal background checks for all firearms alone (without a state permitting system) were not associated with overall homicide rates (percentage change, 1.3%; 95% CI, -6.9% to 10.4%) or firearm homicide rates (percentage change, 3.7%; 95% CI, -5.3% to 13.6%). A law requiring a permit for the purchase of all firearms was associated with significantly lower overall homicide rates (percentage change, -15.4%; 95% CI, -28.5% to -0.01%) and firearm homicide rates (percentage change, -18.3%; 95% CI, -32.0% to -1.9%). Conclusions and Relevance: This cross-sectional study found that universal background checks alone were not associated with firearm homicide rates, but a permit requirement for the purchase and possession of firearms was associated with substantially reduced rates of firearm homicide. The findings suggest that combining universal background checks and permit-to-purchase requirements is an effective strategy for firearm-related fatality reduction.

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