Contextual Determinants of Time to Surgery for Patients With Hip Fracture.

Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions. Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals. Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022. Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds). Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work. Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

Rates, Barriers, and Facilitators of Outcome Collection on Hand Surgery Outreach to Low- and Middle-Income Countries.

BACKGROUND: Global outreach to low- and middle-income countries (LMICs) continues to grow in an effort to improve global health. The practice of quality measurement is empirically lacking from surgical outreach trips to LMICs, which may limit the safety and quality of care provided. Using convergent mixed-methods, we aimed to: (1) identify and evaluate barriers and facilitators to outcome measure collection; and (2) report the sample rate of such collection on hand surgery outreach trips to LMICs. METHODS: Surgeons and administrators involved in hand surgery outreach trips completed a survey regarding rates of outcome measure collection and a semi-structured interview to explore barriers and facilitators of outcome collection. Survey data were reported descriptively. Interviews were recorded and transcribed, and excerpts were categorized according to the Pettigrew framework for strategic change (content, process, and context). Results were combined through convergent mixed-methods analysis. RESULTS: Thirty-three participants completed the survey, and 21 participated in interviews. Rates of collection were the most common for total case number (83%) and patient mortality (65%). Longitudinal outcomes (eg, patient follow-up or time away from work) were less frequently recorded (9% and 4%, respectively). Content analysis revealed barriers related to each domain of the Pettigrew framework. CONCLUSIONS: This analysis demonstrates low levels of outcome collection on outreach trips and identifies priority areas for improvement. Developing context-specific solutions aimed at addressing barriers (eg, resource/database availability) and promoting facilitators (eg, collaborative relationships) may encourage higher rates of collection, which stands to improve patient safety, quality of care, and accountability when conducting outreach trips to LMICs.

A Framework and Blueprint for Building Capacity in Global Orthopaedic Surgical Outreach.

BACKGROUND: Nongovernmental organizations (NGOs) from high-income countries provide surgical outreach for patients in low and middle-income countries (LMICs); however, these efforts lack a coordinated measurement of their ability to build capacity. While the World Health Organization and others recommend outreach trips that aim to build the capacity of the local health-care system, no guidance exists on how to accomplish this. The objective of this paper is to establish a framework and a blueprint to guide the operations of NGOs that provide outreach to build orthopaedic surgical capacity in LMICs. METHODS: We conducted a qualitative analysis of semistructured interviews with 16 orthopaedic surgeons and administrators located in 7 countries (6 LMICs) on the necessary domains for capacity-building; the analysis was guided by a literature review of capacity-building frameworks. We subsequently conducted a modified nominal group technique with a consortium of 10 U.S.-based surgeons with expertise in global surgical outreach, which was member-checked with 8 new stakeholders from 4 LMICs. RESULTS: A framework with 7 domains for capacity-building in global surgical outreach was identified. The domains included professional development, finance, partnerships, governance, community impact, culture, and coordination. These domains were tiered in a hierarchical system to stratify the level of capacity for each domain. A blueprint was developed to guide the operations of an organization seeking to build capacity. CONCLUSIONS: The developed framework identified 7 domains to address when building capacity during global orthopaedic surgical outreach. The framework and its tiered system can be used to assess capacity and guide capacity-building efforts in LMICs. The developed blueprint can inform the operations of NGOs toward activities that focus on building capacity in order to ensure a measured and sustained impact.

"Husband, father, coward, killer": The discursive reproduction of racial inequality in media accounts of mass shooters.

Relying on more expansive criteria for defining "mass shootings" than much existing research, we examine a subset of a unique dataset incorporating 7,048 news documents covering 2,170 shootings in the United States between 2013 and 2019. We analyze the descriptive language used to describe incidents and perpetrators and discover significant racial disparities in representation. This research enables a critical examination of the explanatory frames utilized by news media to tell the public who mass shooters are and journalistic attempts to explain why they occur. Data were analyzed utilizing a mixed methods approach, relying on content analysis to inductively code emergent categories of descriptions of shooters and binary logistic regressions to analyze the preponderance of descriptive categories when comparing news articles reporting on shootings committed by differently racialized shooters. Our results confirm some recent research showing that mass shooters racialized as white are more likely to be described with kind and compassionate language. With our larger sample, however, we also find that mass shooters racialized as white are additionally more likely to be described with negative language as "bad" or "evil" in comparison to shooters of color. We discuss how these data demonstrate that media reports present a more complex picture of white mass shooters for the public than shooters of color.

Patient-Derived Framework for Quality in Hand Surgery: A Qualitative Analysis.

PURPOSE: Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery. METHODS: Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective. RESULTS: Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care. CONCLUSIONS: Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients. CLINICAL RELEVANCE: The themes identified in this study can inform efforts towards patient-centered quality measure development.

Rapid and continuous fabrication of TiO2 nanoparticles encapsulated by polyimide fine particles using a multistep flow-system and their application.

PI fine particles encapsulating a large number of TiO2 nanoparticles (PI FPs/TiO2 NPs) were successfully fabricated rapidly and continuously by the emulsion re-precipitation method using a multistep flow synthetic system. The fabricated material, PI FPs/TiO2 NPs, was spherical in structure with a diameter of 214 nm, and the mean size of TiO2 NPs was 5.2 nm. Line scan elemental analysis with SEM-EDX showed that the TiO2 NPs were disproportionately embedded near the surface of the PI FPs. UV-vis transmission spectra revealed high UV shielding efficiency of the PI FPs/TiO2 NPs as the NPs are located near the surface.

Defining Pt-compressed CO2 synergy for selectivity control of furfural hydrogenation.

The development of a sustainable methodology for catalytic transformation of biomass-derived compounds to value-added chemicals is highly challenging. Most of the transitions are dominated by the use of additives, complicated reaction steps and large volumes of organic solvents. Compared to traditional organic solvents, alternative reaction media, which could be an ideal candidate for a viable extension of biomass-related reactions are rarely explored. Here, we elucidate a selective and efficient transformation of a biomass-derived aldehyde (furfural) to the corresponding alcohol, promoted in compressed CO2 using a Pt/Al2O3 catalyst. Furfural contains a furan ring with C[double bond, length as m-dash]C and an aldehyde group, and is extremely reactive in a hydrogen atmosphere, resulting in several by-products and a threat to alcohol selectivity as well as catalyst life. The process described has a very high reaction rate (6000 h-1) with an excellent selectivity/yield (99%) of alcohol, without any organic solvents or metal additives. This strategy has several key features over existing methodologies, such as reduced waste, and facile product separation and purification (reduced energy consumption). Combining the throughput of experimental observation and molecular dynamics simulation, indeed the high diffusivity of compressed CO2 controls the mobility of the compound, and eventually maintains the activity of the catalyst. Results are also compared for different solvents and solvent-less conditions. In particular, combination of an effective Pt catalyst with compressed CO2 provides an encouraging alternative solution for upgradation of biomass related platform molecules.

An efficient cleavage of the aryl ether C-O bond in supercritical carbon dioxide-water.

A simple and highly efficient Rh/C catalyzed route for the cleavage of the C-O bond of aromatic ether at 80 °C in the presence of 0.5 MPa of H2 in the scCO2-water medium is reported; CO2 pressure and water play a key role under the tested conditions.

Continuous process for fabrication of size controlled polyimide nanoparticles using microfluidic system.

A new strategy has been developed for continuous preparation of polyimide nanoparticles within 10 s of short residence time using a system combining a micromixer and a micro heat exchanger, where the particle size can be controlled proportionally simply by varying the concentration of poly(amic acid) (PAA).

Preparation of silica sphere with porous structure in supercritical carbon dioxide.

Silica sphere with porous structure has been synthesized in supercritical carbon dioxide. The structure originates from a delicate CO(2) trapping phenomenon intended for void formation in the inorganic framework. Silicate polymerization and subsequent removal of CO(2) by depressurization leaves the porous architecture. The key factor to obtain stable porous spherical structure was CO(2) pressure. Different characterization techniques such as X-ray diffraction, scanning and transmission electron microscopy and N(2) adsorption-desorption isotherm were used to determine the framework structure, morphology and porosity of the material. Microscopic visualization of calcined material suggested that the spherical structure was consisted of macroporous windows of diameter approximately 100 nm and the space between macropores presents a wormhole like mesoporous/microporous structure. The pore diameter of the mesoporous structure has been calculated as approximately 3 nm. X-ray diffraction and N(2) adsorption isotherm analysis confirmed the presence of micropores and also the macropores. In addition, the resulting material possess high thermal and hydrothermal stability associated with fully SiO(4) cross-linking. The spherical structure with different types of porosity was successfully obtained without using any molding agent.

Development of a novel catalytic membrane reactor for heterogeneous catalysis in supercritical CO2.

A novel type of high-pressure membrane reactor has been developed for hydrogenation in supercritical carbon dioxide (scCO(2)). The main objectives of the design of the reactor are the separate feeding of hydrogen and substrate in scCO(2) for safe reactions in a continuous flow process, and to reduce the reaction time. By using this new reactor, hydrogenation of cinnamaldehyde into hydrocinnamaldehyde has been successfully carried out with 100% selectivity at 50 degrees C in 10 MPa (H(2): 1 MPa, CO(2): 9 MPa) with a flow rate of substrate ranging from 0.05 to 1.0 mL/min.

Highly efficient chemoselective N-acylation with water microreaction system in the absence of catalyst.

A high-speed, highly efficient chemoselective N-acylation by anhydride was achieved in the absence of catalyst for exothermic (DeltaH>0) and endothermic (DeltaH<0) acylation of various amines and anilines with the microreaction system of ambient water (micro-onH2O) and subcritical water (micro-subH2O), where the desired N-acylated products are chemoselectively obtained with high yield(s) and excellent selectivity (>95%).

An exceptionally rapid and selective hydrogenation of 2-cyclohexen-1-one in supercritical carbon dioxide.

Selective hydrogenation of 2-cyclohexen-1-one over Pt-MCM-41 proceeds at a very high rate and produces cyclohexanone with selectivity of 100% in a batch reactor; a marked increase in the reaction rate (TOF) from 2283 min(-1) to 5051 min(-1) is observed on increasing the pressure from 7 MPa to 14 MPa at 40 degrees C.