Instituting a Palliative Care Trigger in a Surgical Intensive Care Unit (SICU): Survey Results of SICU Team Members.

Increasing palliative care presence in the intensive care unit (ICU) improves symptom management, increases goals-of-care discussion, and reduces unnecessary procedures in ICU patients. An interdisciplinary study team developed a palliative care trigger program in a 17-bed surgical ICU (SICU). Surgical ICU patients who met 3 triggers (ICU length of stay > 10 days, repeat ICU admission, and metastatic cancer) automatically received a palliative care consult. The purpose of the current study was to survey SICU health care professionals before and after the institution of the palliative care trigger program. Overall, the palliative care trigger program was viewed positively by interdisciplinary team members with increased team communication and decreased resistance for the inclusion of palliative care in the SICU plan of care. The palliative care trigger program was successfully developed and implemented in a SICU and was accepted by the interdisciplinary team members caring for SICU patients. Team member feedback is being used to expand the palliative care trigger program to improve care for SICU patients.

Methanetriol─Formation of an Impossible Molecule.

Orthocarboxylic acids─organic molecules carrying three hydroxyl groups at the same carbon atom─have been distinguished as vital reactive intermediates by the atmospheric science and physical (organic) chemistry communities as transients in the atmospheric aerosol cycle. Predicted short lifetimes and their tendency to dehydrate to a carboxylic acid, free orthocarboxylic acids, signify one of the most elusive classes of organic reactive intermediates, with even the simplest representative methanetriol (CH(OH)3)─historically known as orthoformic acid─not previously been detected experimentally. Here, we report the first synthesis of the previously elusive methanetriol molecule in low-temperature mixed methanol (CH3OH) and molecular oxygen (O2) ices subjected to energetic irradiation. Supported by electronic structure calculations, methanetriol was identified in the gas phase upon sublimation via isomer-selective photoionization reflectron time-of-flight mass spectrometry combined with isotopic substitution studies and the detection of photoionization fragments. The first synthesis and detection of methanetriol (CH(OH)3) reveals its gas-phase stability as supported by a significant barrier hindering unimolecular decomposition. These findings progress our fundamental understanding of the chemistry and chemical bonding of methanetriol, hydroxyperoxymethane (CH3OOOH), and hydroxyperoxymethanol (CH2(OH)OOH), which are all prototype molecules in the oxidation chemistry of the atmosphere.

Interstellar formation of glyceric acid [HOCH2CH(OH)COOH]-The simplest sugar acid.

Glyceric acid [HOCH2CH(OH)COOH]-the simplest sugar acid-represents a key molecule in biochemical processes vital for metabolism in living organisms such as glycolysis. Although critically linked to the origins of life and identified in carbonaceous meteorites with abundances comparable to amino acids, the underlying mechanisms of its formation have remained elusive. Here, we report the very first abiotic synthesis of racemic glyceric acid via the barrierless radical-radical reaction of the hydroxycarbonyl radical (HOCO) with 1,2-dihydroxyethyl (HOCHCH2OH) radical in low-temperature carbon dioxide (CO2) and ethylene glycol (HOCH2CH2OH) ices. Using isomer-selective vacuum ultraviolet photoionization reflectron time-of-flight mass spectrometry, glyceric acid was identified in the gas phase based on the adiabatic ionization energies and isotopic substitution studies. This work reveals the key reaction pathways for glyceric acid synthesis through nonequilibrium reactions from ubiquitous precursor molecules, advancing our fundamental knowledge of the formation pathways of key biorelevant organics-sugar acids-in deep space.

Bottom-Up Formation of Antiaromatic Cyclobutadiene (c-C4H4) in Interstellar Ice Analogs.

Antiaromatic cyclobutadiene (c-C4H4) is the simplest prototype of [n]annulenes and a key reactive intermediate with significant ring strain, serving as the model compound for antiaromatic systems in organic chemistry. Here, we report the first bottom-up formation of cyclobutadiene in low-temperature acetylene (C2H2) ices exposed to energetic electrons. Cyclobutadiene was isolated and detected in the gas phase upon sublimation utilizing vacuum ultraviolet photoionization reflectron time-of-flight mass spectrometry along with ultraviolet photolysis studies. These findings advance our fundamental understanding of the exotic chemistry and preparation of highly strained antiaromatic cycles through non-equilibrium chemistry in interstellar environments, thus affording a possible route for the formation of highly strained molecules such as the hitherto elusive tetrahedrane (C4H4). Because acetylene is a major product of the photolysis and radiolysis of methane (CH4) ice, an abundant component of interstellar ices, our results suggest that cyclobutadiene can likely be formed in methane-rich ices of cold molecular clouds.

Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

Ultraviolet-Initiated Decomposition of Solid 1,1-Diamino-2,2-dinitroethylene (FOX-7).

FOX-7 (1,1-diamino-2,2-dinitroethylene) was photolyzed with 202 nm photons to probe reaction energies, leading to the decomposition of this energetic material and to compare results from irradiations using lower-energy 532 and 355 nm photons as well as higher-energy electrons. The photolysis occurred at 5 K to suppress thermal reactions, and the solid samples were monitored using Fourier transform infrared spectroscopy (FTIR), which observed carbon dioxide (CO2), carbon monoxide (CO), cyanide (CN-), and cyanate (OCN-) after irradiation. During warming to 300 K, subliming products were detected using electron-impact quadrupole mass spectrometry (EI-QMS) and photoionization time-of-flight mass spectrometry (PI-ReTOF-MS). Five products were observed in QMS: water (H2O), carbon monoxide (CO), nitric oxide (NO), carbon dioxide (CO2), and cyanogen (NCCN). The ReTOF-MS results showed overlap with electron irradiation products but also included three intermediates for the oxidation of ammonia and nitric oxide: hydroxylamine (NH2OH), nitrosamine (NH2NO), and the largest product at 76 amu with the proposed assignment of hydroxyurea (NH2C(O)NHOH). These results highlight the role of reactive oxygen intermediates and nitro-to-nitrite isomerization as key early reactions that lead to a diverse array of decomposition products.

Pt+(C2H2)n Complexes Studied with Selected-Ion Infrared Spectroscopy.

Platinum cation complexes with multiple acetylene molecules are studied with mass spectrometry and infrared laser spectroscopy. Complexes of the form Pt+(C2H2)n are produced in a molecular beam by laser vaporization, analyzed with a time-of-flight mass spectrometer, and selected by mass for studies of their vibrational spectroscopy. Photodissociation action spectra in the C-H stretching region are compared to the spectra predicted for different structural isomers using density functional theory. The comparison between experiment and theory demonstrates that platinum forms cation-π complexes with up to three acetylene molecules, producing an unanticipated asymmetric structure for the three-ligand complex. Additional acetylenes form solvation structures around this three-ligand core. Reacted structures that couple acetylene molecules (e.g., to form benzene) are found by theory to be energetically favorable, but their formation is inhibited under the conditions of these experiments by large activation barriers.

Synthesis of interstellar propen-2-ol (CH3C(OH)CH2) - the simplest enol tautomer of a ketone.

Enols - tautomers of ketones or aldehydes - are anticipated to be ubiquitous in the interstellar medium and play a key role in the formation of complex organic molecules in deep space, but their fundamental formation mechanisms have remained largely elusive as of now. Here we present a combined experimental and computational study demonstrating the first preparation of propen-2-ol (CH3C(OH)CH2) and its isomer methyl vinyl ether (CH3OCHCH2) in low-temperature acetone (CH3COCH3) ices upon exposure to energetic electrons. Propen-2-ol is the simplest enol tautomer of a ketone. Exploiting tunable vacuum ultraviolet photoionization in conjunction with reflectron time-of-flight mass spectrometry, propen-2-ol and methyl vinyl ether were monitored in the gas phase upon sublimation during the temperature-programmed desorption process suggesting that both isomers are promising candidates for future astronomical searches such as via the James Webb Space Telescope. Electronic structure calculations reveal that the barrier of keto-enol tautomerization can be reduced by more than a factor of two (162 kJ mol-1) through the involvement of solvating water molecules under realistic conditions on interstellar grains. The implicit solvent effects, i.e., the influences of the solvent dipole field on the barrier height are found to be minimal and do not exceed 10 kJ mol-1. Our findings signify a crucial step toward a better understanding of the enolization of ketones in the interstellar medium thus constraining the molecular structures and complexity of molecules that form in extraterrestrial ices - ketones - through non-equilibrium chemistry.

Quantum Tunneling Mediated Low-Temperature Synthesis of Interstellar Hemiacetals.

Sugars and sugar-related molecules are ubiquitous in carbonaceous meteorites and in star-forming regions, but the underlying mechanisms of their formation have remained largely elusive. Herein, we report an unconventional synthesis of the hemiacetal, (R/S)-1-methoxyethanol (CH3OCH(OH)CH3), through quantum tunneling mediated reactions in low-temperature interstellar model ices composed of acetaldehyde (CH3CHO) and methanol (CH3OH). The detection of racemic 1-methoxyethanol through a bottom-up synthesis from simple, abundant precursor molecules within interstellar ices represents a vital starting point to the formation of complex interstellar hemiacetals. Once synthesized, hemiacetals may act as possible precursors to interstellar sugars and sugar-related molecules in deep space.

Electron-Induced Decomposition of Solid 1,1-Diamino-2,2-dinitroethylene (FOX-7) at Cryogenic Temperatures.

Solid FOX-7 (1,1-diamino-2,2-dinitroethylene), an energetic material of interest due to its high stability and low shock/thermal sensitivity, was exposed to energetic electrons at 5 K to explore the fundamental mechanisms leading to decomposition products and provide a better understanding of the reaction pathways involved. As a result of the radiation exposure, infrared spectroscopy revealed carbon dioxide (CO2) and carbon monoxide (CO) trapped in the FOX-7 matrix, while these compounds along with water (H2O), nitrogen monoxide (NO), and cyanogen (C2N2) were detected exploiting quadrupole mass spectrometry both during irradiation and during the warming phase from 5 to 300 K. Photoionization reflectron time-of-flight mass spectrometry detected small molecules such as ammonia (NH3), nitrogen monoxide (NO), and nitrogen dioxide (NO2) as well as more complex molecules up to 96 amu. Potential reaction pathways are presented and assignments are discussed. Among the reaction mechanisms, the importance of an initial nitro-to-nitrite isomerization is highlighted by the observed decomposition products.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Gas-phase detection of oxirene.

Oxirenes-highly strained 4π Hückel antiaromatic organics-have been recognized as key reactive intermediates in the Wolff rearrangement and in interstellar environments. Predicting short lifetimes and tendency toward ring opening, oxirenes are one of the most mysterious classes of organic transients, with the isolation of oxirene (c-C2H2O) having remained elusive. Here, we report on the preparation of oxirene in low-temperature methanol-acetaldehyde matrices upon energetic processing through isomerization of ketene (H2CCO) followed by resonant energy transfer of the internal energy of oxirene to the vibrational modes (hydroxyl stretching and bending, methyl deformation) of methanol. Oxirene was detected upon sublimation in the gas phase exploiting soft photoionization coupled with a reflectron time-of-flight mass spectrometry. These findings advance our fundamental understanding of the chemical bonding and stability of cyclic, strained molecules and afford a versatile strategy for the synthesis of highly ring-strained transients in extreme environments.

Prebiotic Synthesis and Isomerization in Interstellar Analog Ice: Glycinal, Acetamide, and Their Enol Tautomers.

Glycinal (HCOCH2 NH2 ) and acetamide (CH3 CONH2 ) are simple molecular building blocks of biomolecules in prebiotic chemistry, though their origin on early Earth and formation in interstellar media remain a mystery. These molecules are formed with their tautomers in low temperature interstellar model ices upon interaction with simulated galactic cosmic rays. Glycinal and acetamide are accessed via barrierless radical-radical reactions of vinoxy (⋅CH2 CHO) and acetyl (⋅C(O)CH3 ), and then undergo keto-enol tautomerization. Exploiting tunable photoionization reflectron time-of-flight mass spectroscopy and photoionization efficiency (PIE) curves, these results demonstrate fundamental reaction pathways for the formation of complex organics through non-equilibrium ice reactions in cold molecular cloud environments. These molecules demonstrate an unconventional starting point for abiotic synthesis of organics relevant to contemporary biomolecules like polypeptides and cell membranes in deep space.

Low-Temperature Thermal Formation of the Cyclic Methylphosphonic Acid Trimer [c-(CH3 PO2 )3 ].

We report the formation of the cyclic methylphosphonic acid trimer [c-(CH3 PO2 )3 ] through condensation reactions during thermal processing of low-temperature methylphosphonic acid samples exploiting photoionization reflectron time-of-flight mass spectrometry (PI-ReTOF-MS) along with electronic structure calculations. Cyclic methylphosphonic acid trimers are formed in the solid state and detected together with its protonated species in the gas phase upon single photon ionization. Our studies provide an understanding of the preparation of phosphorus-bearing potentially prebiotic molecules and the fundamental knowledge of low-temperature phosphorus chemistry in extraterrestrial environments.

Mechanistical study on the formation of hydroxyacetone (CH3COCH2OH), methyl acetate (CH3COOCH3), and 3-hydroxypropanal (HCOCH2CH2OH) along with their enol tautomers (prop-1-ene-1,2-diol (CH3C(OH)CHOH), prop-2-ene-1,2-diol (CH2C(OH)CH2OH), 1-methoxyethen-1-ol (CH3OC(OH)CH2) and prop-1-ene-1,3-diol (HOCH2CHCHOH)) in interstellar ice analogs.

We unravel, for the very first time, the formation pathways of hydroxyacetone (CH3COCH2OH), methyl acetate (CH3COOCH3), and 3-hydroxypropanal (HCOCH2CH2OH), as well as their enol tautomers within mixed ices of methanol (CH3OH) and acetaldehyde (CH3CHO) analogous to interstellar ices in the ISM exposed to ionizing radiation at ultralow temperatures of 5 K. Exploiting photoionization reflectron time-of-flight mass spectrometry (PI-ReToF-MS) and isotopically labeled ices, the reaction products were selectively photoionized allowing for isomer discrimination during the temperature-programmed desorption phase. Based on the distinct mass-to-charge ratios and ionization energies of the identified species, we reveal the formation pathways of hydroxyacetone (CH3COCH2OH), methyl acetate (CH3COOCH3), and 3-hydroxypropanal (HCOCH2CH2OH) via radical-radical recombination reactions and of their enol tautomers (prop-1-ene-1,2-diol (CH3C(OH)CHOH), prop-2-ene-1,2-diol (CH2C(OH)CH2OH), 1-methoxyethen-1-ol (CH3OC(OH)CH2) and prop-1-ene-1,3-diol (HOCH2CHCHOH)) via keto-enol tautomerization. To the best of our knowledge, 1-methoxyethen-1-ol (CH3OC(OH)CH2) and prop-1-ene-1,3-diol (HOCH2CHCHOH) are experimentally identified for the first time. Our findings help to constrain the formation mechanism of hydroxyacetone and methyl acetate detected within star-forming regions and suggest that the hitherto astronomically unobserved isomer 3-hydroxypropanal and its enol tautomers represent promising candidates for future astronomical searches. These enol tautomers may contribute to the molecular synthesis of biologically relevant molecules in deep space due to their nucleophilic character and high reactivity.

Assessing the Feasibility and Implementation of Palliative Care Triggers in a Surgical Intensive Care Unit to Improve Interdisciplinary Collaboration for Patient and Family Care.

Although palliative care focuses on supporting patients and families through serious illness, it is underutilized in the surgical intensive care unit (SICU). In 2020, patients in the SICU represented only 2.75% of our palliative team's consults. We hypothesize that utilization of palliative care triggers in the SICU will increase collaboration between SICU and palliative care teams and improve patient/family experiences. After reviewing our team's consultation records and the published literature, a consult trigger program was implemented for patients with a SICU length of stay >10 days, unplanned SICU readmission, or new diagnosis of metastatic cancer. A pre-intervention survey assessed SICU providers' perceptions of palliative care. Retrospective analysis evaluated qualitative and quantitative measures. 97% of SICU providers felt increased palliative care would be helpful. During the 6-month project, January 1, 2021 - June 30, 2021, our palliative team performed 27 triggered consults, representing 3.3% of the total 818 consults performed during this period and thus a 20% increase in SICU palliative consults. Triggered consults represented many primary surgical services and the most common consult reason was length-of-stay. All consults included discussions about goals of care and 16 of the 27 patients/families expressed restorative goals. Numerous notes documented family appreciation.

Thermal Synthesis of Carbamic Acid and Its Dimer in Interstellar Ices: A Reservoir of Interstellar Amino Acids.

Reactions in interstellar ices are shown to be capable of producing key prebiotic molecules without energetic radiation that are necessary for the origins of life. When present in interstellar ices, carbamic acid (H2NCOOH) can serve as a condensed-phase source of the molecular building blocks for more complex proteinogenic amino acids. Here, Fourier transform infrared spectroscopy during heating of analogue interstellar ices composed of carbon dioxide and ammonia identifies the lower limit for thermal synthesis to be 62 ± 3 K for carbamic acid and 39 ± 4 K for its salt ammonium carbamate ([H2NCOO-][NH4+]). While solvation increases the rates of formation and decomposition of carbamic acid in ice, the absence of solvent effects after sublimation results in a significant barrier to dissociation and a stable gas-phase molecule. Photoionization reflectron time-of-flight mass spectrometry permits an unprecedented degree of sensitivity toward gaseous carbamic acid and demonstrates sublimation of carbamic acid from decomposition of ammonium carbamate and again at higher temperatures from carbamic acid dimers. Since the dimer is observed at temperatures up to 290 K, similar to the environment of a protoplanetary disk, this dimer is a promising reservoir of amino acids during the formation of stars and planets.

Coordination and Spin States in Fe+(C2H2)n Complexes Studied with Selected-Ion Infrared Spectroscopy.

Fe+(acetylene)n ion-molecule complexes are produced in a supersonic molecular beam with pulsed laser vaporization. These ions are mass selected and studied with infrared photodissociation spectroscopy in the C-H stretching region, complemented by computational chemistry calculations. All C-H stretch vibrations are shifted to frequencies lower than the vibrations of isolated acetylene because of the charge transfer that occurs between the metal ion and the molecules. Complexes in the size range of n = 1-4 are found to have structures with individual acetylene molecules bound to the core metal ion via cation-π interactions. The coordination is completed with four ligands in a structure close to a distorted tetrahedron. Larger complexes in the range of n = 5-8 have external acetylene molecules solvating this n = 4 core ion via CH-π bonding to inner-shell ligands. DFT computations predict that quartet spin states are more stable for all complex sizes, but infrared spectra for quartet and doublet spin states are quite similar, precluding definitive determination of the spin states. There is no evidence for any of these complexes having acetylenes coupled into reacted structures. This is consistent with computed thermochemistry, which finds significant activation barriers to such reactions.

Preparation of methanediamine (CH2(NH2)2)-A precursor to nucleobases in the interstellar medium.

Although methanediamine (CH2(NH2)2) has historically been the subject of theoretical scrutiny, it has never been isolated to date. Here, we report the preparation of methanediamine (CH2(NH2)2)-the simplest diamine. Low-temperature interstellar analog ices composed of ammonia and methylamine were exposed to energetic electrons which act as proxies for secondary electrons produced in the track of galactic cosmic rays. These experimental conditions, which simulate the conditions within cold molecular clouds, result in radical formation and initiate aminomethyl (CH2NH2) and amino ([Formula: see text]2) radical chemistry. Exploiting tunable photoionization reflectron time-of-flight mass spectrometry (PI-ReToF-MS) to make isomer-specific assignments, methanediamine was identified in the gas phase upon sublimation, while its isomer methylhydrazine (CH3NHNH2) was not observed. The molecular formula was confirmed to be CH6N2 through the use of isotopically labeled reactants. Methanediamine is the simplest molecule to contain the NCN moiety and could be a vital intermediate in the abiotic formation of heterocyclic and aromatic systems such as nucleobases, which all contain the NCN moiety.