Interfacial Ice Density Fluctuations Inform Surface Ice-Philicity.

The propensity of a surface to nucleate ice or bind to ice is governed by its ice-philicity─its relative preference for ice over liquid water. However, the relationship between the features of a surface and its ice-philicity is not well understood, and for surfaces with chemical or topographical heterogeneity, such as proteins, their ice-philicity is not even well-defined. In the analogous problem of surface hydrophobicity, it has been shown that hydrophobic surfaces display enhanced low water-density (vapor-like) fluctuations in their vicinity. To interrogate whether enhanced ice-like fluctuations are similarly observed near ice-philic surfaces, here we use molecular simulations and enhanced sampling techniques. Using a family of model surfaces for which the wetting coefficient, k, has previously been characterized, we show that the free energy of observing rare interfacial ice-density fluctuations decreases monotonically with increasing k. By utilizing this connection, we investigate a set of fcc systems and find that the (110) surface is more ice-philic than the (111) or (100) surfaces. By additionally analyzing the structure of interfacial ice, we find that all surfaces prefer to bind to the basal plane of ice, and the topographical complementarity of the (110) surface to the basal plane explains its higher ice-philicity. Using enhanced interfacial ice-like fluctuations as a measure of surface ice-philicity, we then characterize the ice-philicity of chemically heterogeneous and topologically complex systems. In particular, we study the spruce budworm antifreeze protein (sbwAFP), which binds to ice using a known ice-binding site (IBS) and resists engulfment using nonbinding sites of the protein (NBSs). We find that the IBS displays enhanced interfacial ice-density fluctuations and is therefore more ice-philic than the two NBSs studied. We also find the two NBSs are similarly ice-phobic. By establishing a connection between interfacial ice-like fluctuations and surface ice-philicity, our findings thus provide a way to characterize the ice-philicity of heterogeneous surfaces.

A Regional Survey of Attitudes and Experiences in Determining When to Prescribe Intranasal Naloxone for Patients Seen in Palliative Care Clinics in the United States of America.

Background: Published guidelines that help clinicians identify patients who would benefit from the co-prescription of intranasal naloxone (IN) exclude "palliative care patients." In the absence of clear care standards, palliative care (PC) clinicians may experience uncertainty in how to approach IN co-prescriptions. Objective: Explore the attitudes of PC clinicians in the United States of America who work at regional health care institutions regarding IN prescriptions for patients they prescribe opioids for. Methods: An 18-question electronic survey was distributed to PC clinicians that practice at institutions in Wisconsin or Minnesota with at least 10 other PC clinicians between February and May 2023. The survey explored clinical scenarios in which respondents would and would not prescribe IN. Results: Fifty-six PC clinicians responded to the survey-response rate 41%. Most respondents (90.9%) did not feel IN prescriptions should be reserved for patients with a full code status; 67.9% of respondents felt that IN prescriptions are reasonable for certain patients with a terminal illness and comfort goals of care. Neither prognosis, duration of opioid therapy, nor dose of opioid therapy were significant factors in determining whether most respondents prescribed IN for their patients. Most respondents (81.8%) felt clinician counseling and patient consent were essential before prescribing IN. Conclusion: Most PC clinicians in our survey felt that IN prescriptions can be appropriate for patients they prescribe opioids for. Bystander safety was an emerging rationale for why respondents chose to prescribe IN for their patients. Despite public health efforts to make IN more freely available, most respondents felt clinician counseling was essential before prescribing IN for their patients.

On the engulfment of antifreeze proteins by ice.

Antifreeze proteins (AFPs) are remarkable biomolecules that suppress ice formation at trace concentrations. To inhibit ice growth, AFPs must not only bind to ice crystals, but also resist engulfment by ice. The highest supercooling, [Formula: see text], for which AFPs are able to resist engulfment is widely believed to scale as the inverse of the separation, [Formula: see text], between bound AFPs, whereas its dependence on the molecular characteristics of the AFP remains poorly understood. By using specialized molecular simulations and interfacial thermodynamics, here, we show that in contrast with conventional wisdom, [Formula: see text] scales as [Formula: see text] and not as [Formula: see text]. We further show that [Formula: see text] is proportional to AFP size and that diverse naturally occurring AFPs are optimal at resisting engulfment by ice. By facilitating the development of AFP structure-function relationships, we hope that our findings will pave the way for the rational design of AFPs.

Characterizing Surface Ice-Philicity Using Molecular Simulations and Enhanced Sampling.

The formation of ice, which plays an important role in diverse contexts ranging from cryopreservation to atmospheric science, is often mediated by solid surfaces. Although surfaces that interact favorably with ice (relative to liquid water) can facilitate ice formation by lowering nucleation barriers, the molecular characteristics that confer icephilicity to a surface are complex and incompletely understood. To address this challenge, here we introduce a robust and computationally efficient method for characterizing surface ice-philicity that combines molecular simulations and enhanced sampling techniques to quantify the free energetic cost of increasing surface-ice contact at the expense of surface-water contact. Using this method to characterize the ice-philicity of a family of model surfaces that are lattice matched with ice but vary in their polarity, we find that the nonpolar surfaces are moderately ice-phobic, whereas the polar surfaces are highly ice-philic. In contrast, for surfaces that display no complementarity to the ice lattice, we find that ice-philicity is independent of surface polarity and that both nonpolar and polar surfaces are moderately ice-phobic. Our work thus provides a prescription for quantitatively characterizing surface ice-philicity and sheds light on how ice-philicity is influenced by lattice matching and polarity.

A Scoping Review of the Experiences of Adolescents and Young Adults in the ICU, Their Family Members, and Their Health Care Team.

Adolescents and young adults (AYAs) may be cared for in a pediatric or adult ICU. Specific needs of AYAs differ from those of populations typically found in either ICU. This review identifies research focused on experiences of AYAs in ICUs, their family members, and the health care professionals who care for them, revealing limited research about AYAs in ICUs: 10 articles met inclusion criteria and findings revealed that AYAs want to be treated as individuals and need health care professionals to partner with them. Further research is needed to inform developmentally appropriate care and improve serious illness communication.

Intensive Care Unit Nurse: Could We Call a Palliative Care Consult? Intensive Care Unit Provider: It's Too Early. Palliative Care Integration in the Intensive Care Unit: The Struggle to Translate Evidence Into Practice.

Despite evidence regarding the value of palliative care, there remains a translation-to-practice gap in the intensive care setting. The purpose of this article is to describe challenges and propose solutions to palliative care integration through the presentation and discussion of a critical care patient scenario. We also present recommendations for a collaborative palliative care practice framework that holds the potential to improve quality of life for patients and families. Collaborative palliative care is characterized by close working relationships with families, interprofessional intensive care unit healthcare teams, and palliative care specialists. The shortage of palliative care specialists has become a pressing policy and practice issue and highlights the importance of increasing primary palliative care delivery by the intensive care team. Underexplored aspects of collaborative palliative care delivery include the interprofessional communication required, identification of key skills, and expected outcomes. Increased recognition of intensive care unit palliative care as a process of engagement among nurses, providers, patients, and their family members heralds a vital culture shift toward collaborative palliative care. The interprofessional palliative specialist team has the expertise to support intensive care teams in developing their primary palliative skills and recognizing when specialist palliative care support is required. Promotion of strategic palliative care delivery through this collaborative framework has the potential to decrease suffering among patients and families and reduce moral distress among healthcare professionals.

The Pitfalls of Utilizing "Goals of Care" as a Clinical Buzz Phrase: A Case Study and Proposed Solution.

Assistance with discussing goals of care is one of the most common reasons clinicians seek out palliative care consultation. In practice though, the phrase "goals of care" is often utilized as a buzz phrase that lacks a shared understanding of its clinical relevance. We present a case example in which breakdowns in communication occurred between a patient and clinicians due to misunderstandings of the meaning of the phrase "goals of care." Subsequently, we review the literature to propose a unified definition of "goals of care" in hopes to minimize differences in what this phrase implies in clinical practice. We also seek to introduce a standardized process for establishing goals of care that may offer a more reliable and measurable method to promote goal-concordant care.

Attitudes of Liver and Palliative Care Clinicians toward Specialist Palliative Care Consultation for Patients with End-Stage Liver Disease.

Objective: Delays in specialized palliative care (PC) consultation in end-stage liver disease (ESLD) patients may be explained by clinician attitudes toward PC. Our aim is to assess the attitudes of hepatology and liver transplant (HLT) and PC clinicians toward PC consultation and consultant roles in ESLD patient care. Methods: Clinician members of HLT and PC professional societies were surveyed. Using a five-point Likert scale, they rated their comfort level toward various PC consultant roles and their agreement with triggers for and reasons to defer PC consultation. Change in attitudes toward PC consultation resulting from liver transplant (LT) eligibility was evaluated. Results: A total of 311 HLT (6.2%) and 379 PC (8.1%) clinicians completed the survey. The vast majority of HLT clinicians (>80%) were comfortable if PC consultants palliate symptoms, provide support, or facilitate advance care planning in LT-ineligible patients. LT eligibility reduced HLT clinician comfort toward all PC consultant roles, except supportive care. A vast majority of PC clinicians (>90%) were comfortable assuming all PC roles, except pain management without opioids (43-51%). About 80% of HLT clinicians agree with PC consultation in LT-ineligible patients with decompensated cirrhosis or hepatocellular carcinoma (HCC), compared to 20-30% if LT ineligible. Common justifications for deferring PC consultation included mild disease, LT eligibility, unavailability of PC specialists, and lack of addressable palliative issues. Conclusions: Barriers to specialized PC consultation in ESLD include HLT clinician discomfort with PC consultant roles, patients' LT eligibility, perception that PC is end-of-life care, unclear triggers for PC consultation, and concern about opioid-based pain palliation.

Surgery without a surrogate: the low prevalence of healthcare power of attorney documents among preoperative patients.

BACKGROUND: There has been little published research regarding the implementation of healthcare power of attorney (HCPOA) documents prior to elective surgery. OBJECTIVES: This study aims to determine the prevalence of HCPOA documents incorporated into the electronic medical records (EMR) of patients undergoing elective surgery at four healthcare institutions. A secondary aim is to examine for correlations between HCPOA document implementation and demographic and preoperative clinical predictors. METHODS: A retrospective chart review was performed in 2012 on 500 consecutive adult patients undergoing elective surgery that required general anesthesia at four medical centers. A descriptive analysis and multivariate logistic regression analysis were performed to examine for associations between HCPOA implementation and hospital site, age, gender, ASA score, marital status, body mass index, insurance type, and zip code. RESULTS: Of 1723 charts reviewed, only 382 had a HCPOA document implemented within the EMR at the time of surgery with significant variance between hospital sites. Female sex, a widowed marital status, and an ASA score greater than 2 were significantly associated with having a HCPOA implemented in the EMR, while BMI, insurance type, and socioeconomic status based on zip code did not significantly correlate with the rate of HCPOA documentation. CONCLUSIONS: Less than a quarter (22.2%) of patients undergoing elective surgery requiring general anesthesia had a HCPOA document appropriately identified despite the known morbidity and mortality risks. The mere presence of EMR systems, palliative care consultation teams, and preoperative care teams are likely insufficient in ensuring appropriate surrogate documentation prior to elective surgery.