Strategies and Challenges of a Safe Fireplace Program in Rural Kenya: A Qualitative Study.

There is a lack of information on effective burn prevention strategies. The objective of this study was to examine a safe fireplace program, as a method of burn prevention, in a resource-limited setting. We conducted a qualitative, phenomenological study at a community health and development program for a rural population in Kenya. Semi-structured, in-depth interviews were conducted with a purposive sample of community health workers involved with the safe fireplace program. Data were reviewed iteratively and coded independently by two researchers using NVivo 12. The study included five participants. Reflections from participants fell into three main domains: (1) effective methods of education, (2) strategies to incorporate stakeholders, and (3) implementation challenges. The results of this study emphasize the importance of community engagement in implementing a successful burn injury prevention program in a resource-limited setting. The participants involved in this study reported that rather than focusing on resources outside the community, effective methods of education and strategies for incorporating stakeholders depended on involving peers and community leaders. The challenges to the program were similarly specific to community concerns about resources and maintenance. These findings provide information to guide future community health programs in creating successful models for burn prevention strategies in resource-limited areas.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting.

BACKGROUND: Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds. METHODS: A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area. RESULTS: At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas (p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control (p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events. CONCLUSION: ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care.Clincaltrials.gov identifier: NCT04091672. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level I.

Continuous addition kinetic elucidation: catalyst and reactant order, rate constant, and poisoning from a single experiment.

Kinetic analysis of catalytic reactions is a powerful tool for mechanistic elucidation but is often challenging to perform, limiting understanding and therefore development of these reactions. Establishing order in a catalyst is usually achieved by running several reactions at different loadings, which is both time-consuming and complicated by the challenge of maintaining consistent run-to-run experimental conditions. Continuous addition kinetic elucidation (CAKE) was developed to circumvent these issues by continuously injecting a catalyst into a reaction, while monitoring reaction progress over time. For reactions that are mth order in a single yield-limiting reactant and nth order in catalyst, a plot of reactant concentration against time has a shape dependent only on the orders m and n. Therefore, fitting experimental CAKE data (using open access code or a convenient web tool) allows the reactant and catalyst orders, rate constant, and the amount of complete catalyst inhibition to be determined from a single experiment. Kinetic information obtained from CAKE experiments showed good agreement with the literature.

American Burn Association Strategic Quality Summit 2022: Setting the Direction for the Future.

The American Burn Association (ABA) hosted a Burn Care Strategic Quality Summit (SQS) in an ongoing effort to advance the quality of burn care. The goals of the SQS were to discuss and describe characteristics of quality burn care, identify goals for advancing burn care, and develop a roadmap to guide future endeavors while integrating current ABA quality programs. Forty multidisciplinary members attended the two-day event. Prior to the event, they participated in a pre-meeting webinar, reviewed relevant literature, and contemplated statements regarding their vision for improving burn care. At the in-person, professionally facilitated Summit in Chicago, Illinois, in June 2022, participants discussed various elements of quality burn care and shared ideas on future initiatives to advance burn care through small and large group interactive activities. Key outcomes of the SQS included burn-related definitions of quality care, avenues for integration of current ABA quality programs, goals for advancing quality efforts in burn care, and work streams with tasks for a roadmap to guide future burn care quality-related endeavors. Work streams included roadmap development, data strategy, quality program integration, and partners and stakeholders. This paper summarizes the goals and outcomes of the SQS and describes the status of established ABA quality programs as a launching point for futurework.

Anodic and Cathodic Platinum Dissolution Processes Involve Different Oxide Species.

The degradation of Pt-containing oxygen reduction catalysts for fuel cell applications is strongly linked to the electrochemical surface oxidation and reduction of Pt. Here, we study the surface restructuring and Pt dissolution mechanisms during oxidation/reduction for the case of Pt(100) in 0.1 M HClO4 by combining operando high-energy surface X-ray diffraction, online mass spectrometry, and density functional theory. Our atomic-scale structural studies reveal that anodic dissolution, detected during oxidation, and cathodic dissolution, observed during the subsequent reduction, are linked to two different oxide phases. Anodic dissolution occurs predominantly during nucleation and growth of the first, stripe-like oxide. Cathodic dissolution is linked to a second, amorphous Pt oxide phase that resembles bulk PtO2 and starts to grow when the coverage of the stripe-like oxide saturates. In addition, we find the amount of surface restructuring after an oxidation/reduction cycle to be potential-independent after the stripe-like oxide has reached its saturation coverage.

American Burn Association (ABA) Burn Care Quality Platform (BCQP) and Large Data Set Analysis Considerations: A Practical Guide to Investigating Clinical Questions in Burns via Large Data Sets.

The Burn Care Quality Platform (BCQP) consolidates data previously collected from the National Burn Repository and the Burn Quality Improvement Program into a single registry. Its data elements and their associated definitions are tailored to create consistency across other national trauma registries, namely the National Trauma Data Bank implemented by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). The BCQP now includes 103 participating burn centers and has captured data from 375,000 total patients as of 2021. With 12,000 patients entered under the current data dictionary, the BCQP represents the largest registry of its kind. On behalf of the American Burn Association Research Committee, the aim of this whitepaper is to provide a succinct overview of the BCQP, showcasing its unique features, strengths, limitations, and relevant statistical considerations. This whitepaper will highlight the resources available to the burn research community and offer insight on proper study design when preparing to conduct a large data set investigation for burn care. All recommendations herein were formulated through the consensus of a multidisciplinary committee and based on the available scientific evidence.

Driving Force of the Initial Step in Electrochemical Pt(111) Oxidation.

The first step of electrochemical surface oxidation is extraction of a metal atom from its lattice site to a location in a growing oxide. Here we show by fast simultaneous electrochemical and in situ high-energy surface X-ray diffraction measurements that the initial extraction of Pt atoms from Pt(111) is a fast, potential-driven process, whereas charge transfer for the related formation of adsorbed oxygen-containing species occurs on a much slower time scale and is evidently uncoupled from the extraction process. It is concluded that potential plays a key independent role in electrochemical surface oxidation.

EQIP's First Year: A Step Closer to Higher Quality in Surgical Education.

OBJECTIVE: To describe the first year of the Educational Quality Improvement Program (EQIP) DESIGN: The Educational Quality Improvement Program (EQIP) was formed by the Association of Program Directors in Surgery (APDS) in 2018 as a continuous educational quality improvement program. Over 18 months, thirteen discrete goals for the establishment of EQIP were refined and executed through a collaborative effort involving leaders in surgical education. Alpha and beta pilots were conducted to refine the data queries and collection processes. A highly-secure, doubly-deidentified database was created for the ingestion of resident and program data. SETTING & PARTICIPANTS: 36 surgical training programs with 1264 trainees and 1500 faculty members were included in the dataset. 51,516 ERAS applications to programs were also included. Uni- and multi-variable analysis was then conducted. RESULTS: EQIP was successfully deployed within the timeline described in 2020. Data from the ACGME, ABS, and ERAS were merged with manually entered data by programs and successfully ingested into the EQIP database. Interactive dashboards have been constructed for use by programs to compare to the national cohort. Risk-adjusted multivariable analysis suggests that increased time in a technical skills lab was associated with increased success on the ABS's Qualifying Examination, alone. Increased time in a technical skills lab and the presence of a formal teaching curriculum were associated with increased success on both the ABS's Qualifying and Certifying Examination. Program type may be of some consequence in predicting success on the Qualifying Examination. CONCLUSIONS: The APDS has proved the concept that a highly secure database for the purpose of continuous risk-adjusted quality improvement in surgical education can be successfully deployed. EQIP will continue to improve and hopes to include an increasing number of programs as the barriers to participation are overcome.

Generation of Novel Severe Acute Respiratory Syndrome Coronavirus 2 Variants on the B.1.1.7 Lineage in 3 Patients With Advanced Human Immunodeficiency Virus-1 Disease.

The emergence of new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants is of public health concern in case of vaccine escape. Described are 3 patients with advanced human immunodeficiency virus (HIV)-1 and chronic SARS-CoV-2 infection in whom there is evidence of selection and persistence of novel mutations that are associated with increased transmissibility and immune escape.

The APDS General Surgery Education Quality Improvement Program (EQIP).

BACKGROUND: Although the ACGME has called for outcomes-based evaluation of residency programs, few metrics or benchmarks exist connecting educational processes with resident educational outcomes. To address this deficiency, a national Education Quality Improvement Program (EQIP) for General Surgery training is proposed. METHODS: We describe the initial efforts to create this platform. In addition, a national survey was administered to 330 Program Directors to assess their interest in and concerns about a continuous educational quality improvement project. RESULTS: We demonstrate that through a collaborative process and the support of the Association of Program Directors in Surgery (APDS), we were able to develop the groundwork for a national surgical educational improvement project, now called EQIP. The survey response rate was 45.8% (152 of 332 programs) representing a mix of university (55.3%), university-affiliated (18.4%), independent (24.3%), and military (2.0%) programs. Most respondents (66.2%) had not previously heard of EQIP. Most respondents (69.7%) believe that educational outcomes can be measured. The majority of respondents indicated they believed EQIP could be successful (57%). Only 2.3% thought EQIP would not be successful. Almost all programs (98.7%) expressed a willingness to participate, although 19.1% did not believe that they had adequate resources to participate. CONCLUSION: The APDS EQIP platform holds promise as a useful and achievable method to obtain educational outcomes data. These data can be used as a basis for continuous surgical educational quality improvement. General Surgery Program Directors have expressed enthusiasm for EQIP and are willing to participate in the program examining outcomes of General Surgery training programs, with an ultimate goal of improving overall residency training.

Evaluation of 2 commercial anti-SARS-CoV-2 antibody assays in an immunocompetent and immunocompromised inpatient population with COVID-19.

INTRODUCTION: During the COVID-19 pandemic, widespread introduction of SARS-CoV-2 antibody testing was introduced without a full understanding of the assays performance or the antibody kinetics following infection with SARS-CoV-2. METHODS: We performed an evaluation of 2 anti-SARS-CoV-2 antibody assays with a more detailed look into the effect of immune status on antibody sensitivity. RESULTS: Both assays demonstrated 100% specificity. The overall sensitivity of the Roche was 92.1% at ≥14 days and 94.8% at ≥21 days, and the overall sensitivity of the Abbott was 94.4% at ≥14 days and 98.2% at ≥21 days. 7/41 (17%) of patients included in this cohort were immunocompromised. Seroconversion was seen less commonly in the immunocompromised (4/7 [57.1%] seroconverted) and after excluding these patients 100% sensitivity was seen in both assays at ≥21 days. DISCUSSION: Performance of both assays in the immunocompetent appeared excellent after 21 days postsymptom onset. Both assays are highly specific.

Neighborhood risk: Socioeconomic status and hospital admission for pediatric burn patients.

BACKGROUND: Burn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury. STUDY DESIGN: A retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care. RESULTS: We analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (>75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (<75th percentile NRI; 95% CI: 1.08-2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child's likelihood of admission increased by 6% (95% CI: 4-9%). CONCLUSIONS: Children with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.

An Overview of Glycerol Electrooxidation Mechanisms on Pt, Pd and Au.

In the most recent decade, glycerol electrooxidation (GEOR) has attracted extensive research interest for valorization of glycerol: the conversion of glycerol to value-added products. These reactions at platinum, palladium, and gold electrodes have a lot of uncertainty in their reaction mechanisms, which has generated some controversies. This review gathers many reported experimental results, observations and proposed reaction mechanisms in order to draw a full picture of GEOR. A particular focus is the clarification of two propositions: Pd is inferior to Pt in cleaving the C-C bonds of glycerol during the electrooxidation and the massive production of CO2 at high overpotentials is due to the oxidation of the already-oxidized carboxylate products. It is concluded that the inferior C-C bond cleavability with Pd electrodes, as compared with Pt electrodes, is due to the inefficiency of deprotonation, and the massive generation of CO2 as well as other C1/C2 side products is partially caused by the consumption of OH- at the anodes, as a lower pH reduces the amount of carboxylates and favors the C-C bond scission. A reaction mechanism is proposed in this review, in which the generation of side products are directly from glycerol ("competition" between each side product) rather than from the further oxidation of C2/C3 products. Additionally, GEOR results and associated interpretations for Ni electrodes are presented, as well as a brief review on the performances of multi-metallic electrocatalysts (most of which are nanocatalysts) as an introduction to these future research hotpots.

APDS Consensus Statement: Ideal Senior Medical Student Experiences for Preparedness for General Surgery Internship.

OBJECTIVE: Guide optimal standards on ideal senior medical student experiences for preparedness for general surgery internship DESIGN: Work product of task force, approved by the Association of Program Directors in Surgery CONCLUSION: General surgery rotations should mirror the learning and working environment of a surgical intern. Opportunities should mimic the next phase of learning to help guide informed decisions regarding entrustability for entry into residency training. These opportunities will also help identify students who may have an aptitude for pursuing a general surgery internship. Students should achieve entrustability in Association of American Medical Colleges Core Entrustable Professional Activities (EPAs); curricula should align Core EPAs and modified American Board of Surgery EPAs to guide essential general surgery components. Experiences should include required night, holiday, and/or weekend shifts, a dedicated critical care experience, and a resident preparatory curriculum focusing on nontechnical and essential technical skills. We encourage the opportunity for additional surgical mentorship and subspecialty experience through Surgical Interest Groups or Surgical Honors or Specialty Tracks.

Referral Patterns of Burn Injury in Rural Kenya.

Burn injury represents a substantial burden of disease in resource-limited settings. Kenya has no formal trauma system and referral practices for burn injuries are not well understood. The purpose of this study was to determine the factors associated with burn injury referrals in rural Kenya. A retrospective chart review was conducted for patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in southwest Kenya. Bivariate analysis compared referred and non-referred patients. Multivariable logistic regression was used to assess the association between burn severity and odds of referral adjusting for age, sex, insurance, time from injury to arrival, and estimated travel time from home to hospital. The study included 171 patients with burn injury; 11 patients were excluded due to missing referral data. Of the 160 patients, 31.9% (n = 51) were referred. Referral patients had higher average total body surface area burn (23.1 ± 2.4% vs 11.1 ± 1.2%, P < .001), were more likely to have full-thickness burns (41.3% vs 25.5%, P = .05), and less likely to present to the referral hospital within 24 hours after injury (47.8% vs 73.0%, P = .005). Referral patients had longer travel time to hospital (90+ min: 52.9% vs 22.0%, P < .001). Odds of referral increased 1.62 times (95% confidence interval: 1.19-2.22) for every 10% increase in total body surface area burn. Without a coordinated trauma system, referrals represent a substantial portion of burn injury patients at a hospital in rural Kenya. Referred patients present with more severe burns and experience delays to presentation.

APDS Presidential Address.

My goal today is to make an argument that the APDS: is at a crossroads because of unprecedented changes; is in a great position to succeed; seeing the need for change we should nevertheless act consistent with our longstated principles/goals as we negotiate this new path we need to be resolute, bold and brave; the path I hope to convince you of, and which is the subject of this talk, is EQIP (Educational Quality Improvement Project). We humans are in a time of cataclysmic change that rivals fire, the wheel, and the printing press. This change, the digitization of data, allows the collection of vast troves of data that allows healthcare system consolidation, more and more physician oversight, and the subsequent demand for business-like efficiency in the healthcare space. Dramatic changes like this creates collateral damage and can be frustrating for those that live through it. If the APDS is doing its job, we should be able to help Program Directors with these frustrations. The purposes of the APDS since its inception in 1977 is to: provide a forum for the exchange of information related to postgraduate surgical education; maintain high standards of surgical residency training; provide advice, assistance, and support to program directors; encourage research into all aspects of the education and training of surgeons; and represent the interests of program to other organizations. As we look to the future, I think 2 of these purposes should be paramount-research and advocacy. Research and advocacy are the cornerstones of EQIP. Research and advocacy can be linked by one word-truth. We need to seek the truth. We seek truth by collecting and analyzing data. We cannot hide from it, no matter where it leads us. We cannot shy away from the complexity of the search for truth no matter how difficult the process may be. EQIP is a continuous learning quality improvement program run by program directors for program directors to allow for data-driven innovation in surgical education and to allow data-informed conversations about the future of general surgery. EQIP will have a data gathering interface, a data repository and will have data analytics capability and data reporting platform. We are about to begin a 2-year proof of concept journey. So, in this time of great change and momentous challenge why should the APDS answer the bell? We should answer the bell for 4 reasons. We should answer the bell because engagement is a tool of resiliency, engagement solves frustration, and engagement is an antidote to burn-out. We should answer the bell because it gives us a chance to dramatically improve surgical education. We should answer the bell because we are in a great position to do this heavy lift. We should answer the bell because engagement is fun.