Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study.

BACKGROUND: The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19. METHODS: An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. RESULTS: Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. "Inadequate emotional support for patients and their families" was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect,  ethical awareness and support. "Culture of not avoiding end-of-life-decisions" and "Self-reflective and empowering leadership" received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior. CONCLUSION: Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.

Mechanochemical Tailoring of Lignin Structure: Influence of Different Particle Sizes in the Organosolv Process.

The autocatalyzed ethanolic organosolv process is gaining increasing attention for the sulfur-free isolation of lignin, which is subsequently used as a renewable substitute for various fossil-based applications. For the first time, the mechanochemical influence of seven different particle sizes of two different biomasses on the respective organosolv lignin structure is examined. Wine pruning (Pinot Noir) and wine pomace (Accent) are used for organosolv process with particle sizes ranging from 2.0-1.6 mm to less than 0.25 mm. As particle size decreases, the weight-average molecular weight increases, while the total phenol content decreases significantly. Additionally, the distribution of the lignin-typical monolignols and relevant substructures, as determined by two-dimensional heteronuclear nuclear magnetic resonance spectra single quantum coherence (HSQC), is observed. The degree of grinding of the biomass has a clear chemical-structural influence on the isolated HG and HGS organosolv lignins. Therefore, it is crucial to understand this influence to apply organosolv lignins in a targeted manner. In the future, particle size specifications in the context of the organosolv process should be expressed in terms of distribution densities rather than in terms of a smaller than specification.

Improvements to the compressed-sample (CS) technique for MALDI-TOF mass spectrometry.

A recently developed solvent-free compressed-sample technique for matrix-assisted laser desorption/ionization-mass spectrometry (MALDI-MS) analysis allows the reproducible analysis of synthetic polymers and peptides up to 3,500 Da. In this work, we present an improvement in resolution, an increase in intensity and a decrease of the variation coefficient, as illustrated by the analysis of PEG 2000 and MALDI imaging experiments. These advantages were achieved by homogenization of the electrical field, which was disturbed by the drills in the original MALDI target. In order to homogenize the electrical field, a new target with smaller drills was developed, metal powder was added to the matrix/analyte mixture and a round laser raster was used. Furthermore, a ball mill was implemented for the sample preparation to replace the extremely user-dependent grinding in a mortar. The new conditions were successfully applied to the quantification of several peptides of higher molecular weight and gave higher precision than had previously been achieved with the compressed-sample technique.

Evaluation of the Transformation and Leaching Behavior of Two Polyfluoroalkyl Phosphate Diesters in a Field Lysimeter Study.

In this study, 6:2 and 8:2 polyfluoroalkyl phosphate diester (diPAP) were individually investigated in lysimeters under near-natural conditions. Leachate was sampled for 2 years, as was the soil after the experiment. In the leachate of the diPAP-spiked soils, perfluorocarboxylic acids (PFCAs) of different chain lengths were detected [23.2% (6:2 diPAP variant) and 20.8% (8:2 diPAP variant) of the initially applied molar amount]. After 2 years, the soils still contained 36-37% 6:2 diPAP and 41-45% 8:2 diPAP, respectively, in addition to smaller amounts of PFCAs (1.5 and 10.6%, respectively). Amounts of PFCAs found in the grass were low (<0.1% in both variants). The recovery rate of both 6:2 diPAP and 8:2 diPAP did not reach 100% (63.9 and 83.2%, respectively). The transformation of immobile diPAPs into persistent mobile PFCAs and their transport into the groundwater shows a pathway for human exposure to hazardous PFCAs through drinking water and irrigation of crops.

Quantitative matrix-assisted laser desorption ionization-time-of-flight mass spectrometry analysis of synthetic polymers and peptides.

Matrix-assisted laser desorption ionization (MALDI) is a very powerful and widely used mass spectrometric technique to ionize high molecular weight compounds. The most commonly used dried droplet (DD) technique can lead to a concentration distribution of the analyte on the target and is therefore often not suitable for reproducible analyses. We developed a new solvent-free deposition technique, called compressed sample (CS), to prevent the distribution of the analytes caused by the crystallization of the compounds. The CS technique presented in this work allows the quantitative analysis of synthetic polymers such as derivatized maltosides with correlation coefficients of 0.999 and peptides up to 3500 Da with correlation coefficients of at least 0.982 without the use of stable-isotope-labeled standards.

Quantitative investigation of the urinary excretion of three specific monoester metabolites of the plasticizer diisononyl adipate (DINA).

Diisononyl adipate (DINA) is a plasticizer used in PVC products as an alternative for restricted phthalate plasticizers. With this study, we provide first data on human DINA metabolism and excretion. We postulated mono(hydroxy-isononyl) adipate (OH-MINA), mono(oxo-isononyl) adipate (oxo-MINA), and mono(carboxy-isooctyl) adipate (cx-MIOA) as specific DINA metabolites based on the known human metabolism of structurally similar adipates and phthalates. Urinary excretion was quantitatively investigated after a single oral dose (113 to 145 µg/kg body weight) to three healthy volunteers using a newly developed online-SPE-LC-MS/MS method with isotope dilution and LOQs between 0.3 - 0.6 µg/L. OH-MINA turned out to be the major of the three metabolites with consistent urinary excretion fractions (FUEs) of 0.020-0.023 % among all volunteers. Oxo-MINA and cx-MIOA were excreted with lower shares (mean: 0.003 % and 0.009 %, respectively). For all three metabolites, urinary concentrations peaked quickly between 1.4 and 2.3 h post dose with maximum concentrations of 23.1 (OH-MINA), 2.87 (oxo-MINA) and 9.83 µg/L (cx-MIOA). Thus, FUEs and urinary concentrations were rather low for these specific metabolites, with the major share of the dose presumably being excreted as non-specific metabolites such as adipic acid. In a pilot population (n=35) of German adults without known DINA exposure, we could not detect any of the three metabolites, contrary to the dosage study, indicating to population exposures lower than 50 µg/kg body weight/day. The new HBM method in conjunction with the new FUEs can be used for objective DINA exposure and risk assessment especially in populations with potentially higher DINA exposures.

Combination of chemical and electron-impact ionisation with GC x GC-qMS for characterization of fatty alcohol alkoxylate polymers in the low-molecular-weight range up to 700 Da.

The class of fatty alcohol alkoxylates describes surfactants that are synthesised by reaction of fatty alcohols with alkoxides such as ethylene oxide or propylene oxide or a combination of both as copolymers. Such alkoxylates are used, for example, as nonionic surfactants in home and industrial cleaning and washing agents. Chemical characteristics of such alkoxylate copolymers, for example the degree of alkoxylation, the arrangement of building blocks (random or block polymerisation), the type of the starter, and endcapping, play an important role in application behaviour. The analysis of these characteristics is challenging because in many cases such copolymers have high polydispersity and a large number of constitutional isomers depending on the degree of alkoxylation. Furthermore, the alkoxylates often occur in a complex multicomponent matrix. Here we present a method for characterization of silylated fatty alcohol alkoxylates in the low-molecular-weight range by means of comprehensive two-dimensional gas chromatography-mass spectrometry with electron impact and chemical ionisation. This method also enables detailed analysis of the alkoxylates in a complex matrix such as modern detergents.

Fate of Chlorpropham during High-Temperature Processing of Potatoes.

Chlorpropham is a widely used sprouting inhibitor applied on potatoes during their storage. Currently, severe concerns are raised regarding the potential formation of 3-chloroaniline from chlorpropham during heat treatment. The reactions degrading the molecule in the matrix are quite complex under harsh processing conditions, and a molecular investigation is thus challenging. This study aims to decipher the reaction pathways and to discover new metabolites in typical high-temperature food-processing steps. For this purpose, potatoes were treated with 14C-radiolabeled chlorpropham, stored for up to 6 months, and subjected to the traditional preparation steps of boiling, frying, and baking. A quantification method including an acidic hydrolysis was developed for analysis of free and bound analytes. All conducted processing steps led to a substantial mitigation of chlorpropham residues in the consumable products. Of the residues, 17 ± 6% remained in boiled tubers, while 27 ± 3 and 22 ± 3% remained in the fried and baked products, respectively. Chlorpropham was transferred into the surrounding media (boiling water, frying oil, and air, respectively). 3-Chloroaniline was only (raw tubers) or predominantly (processed tubers) present as a bound analyte and was shown to form during storage but not during processing. Additionally, nonextractable and nonquantified residues were detected in the baked and in the long-term-stored tubers after processing. Future studies will have to balance beneficial (mitigating) and potentially hazardous aspects of these results. By transferring the 14C-food-processing approach to a variety of substances, ingredients, and processes, it will be possible to further understand chemical reactions in food processing, finally leading to safer food.

Metabolism and urinary excretion kinetics of di(2-ethylhexyl) adipate (DEHA) in four human volunteers after a single oral dose.

Di(2-ethylhexyl) adipate (DEHA) is used as a substitute for the reprotoxic phthalate plasticizer di(2-ethylhexyl) phthalate (DEHP). This study reports the first quantitative data on human in vivo DEHA metabolism and urinary metabolite excretion with the aim of providing tools for DEHA exposure and risk assessments. After DEHA was administered to four healthy volunteers (107-164 µg/kg body weight (bw)), urine samples were continuously and completely collected for 48 h and analyzed for the specific oxidized monoester metabolites mono-2-ethyl-5-hydroxyhexyl adipate (5OH-MEHA), mono-2-ethyl-5-oxohexyl adipate (5oxo-MEHA), and mono-5-carboxy-2-ethylpentyl adipate (5cx-MEPA), as well as for the non-specific hydrolysis product adipic acid (AA) using stable isotope dilution analysis. AA was confirmed as a major (urinary excretion fraction (FUE): 10-40%), yet non-specific DEHA metabolite. 5cx-MEPA was the major specific DEHA metabolite with an FUE of 0.20% (range: 0.17-0.24%). FUEs for 5OH-MEHA and 5oxo-MEHA were 0.07% (0.03-0.10%) and 0.05% (0.01-0.06%), respectively. The three specific metabolites were excreted with two concentration maxima (tmax1 = 1.5-2.3 h, tmax2 = 3.8-6.4 h). Elimination half-lives (t1/2, calculated after the second tmax) for 5cx-MEPA were calculated between 2.1-3.8 h. The majority (98-100%) of metabolites was excreted within 24 h. The FUE of 5cx-MEPA was applied to demonstrate its applicability for calculating daily intakes based on urinary metabolite levels from three pilot populations. Daily intakes were generally far below the tolerable daily intake (TDI) for DEHA (300 µg/kg bw/day). The highest daily intake (114 µg/kg bw/day) was calculated in individuals after consuming food that had been wrapped in DEHA containing cling film.

Processing Induced Degradation Routes of Prochloraz in Rapeseed Oil.

Analyzing the fate of substances in complex matrices, such as processed food, is a major challenge in modern analytical chemistry. However, current regulatory procedures for pesticides only include high temperature hydrolysis of the active substance in water (OECD 507) to simulate food processing. This study shows that heating radiolabeled [imidazolyl-2-14C]prochloraz in virgin rapeseed oil at temperatures up to 240 °C leads to an extensive degradation of the active substance. In total, 11 degradation products were identified. Several of these products were formed by reactions of the active substance with ingredients from the oil. 2-[(1-H-Imidazole-1-carbonyl)(propyl)amino]ethyl oleate (icpame-oleate), a reaction product of an oleic acid moiety and the prochloraz backbone, was identified for the first time. The quantification of prochloraz, icpame-oleate, imidazole, and 2,4,6-trichlorophenol demonstrated the dependency of the degradation process on temperature, heating duration, and type of oil. The obtained results in this study show the enormous impact of high temperature food processing on the fate of pesticides. The necessity to consider matrix related reactions in pesticide regulation is emphasized, and the suitability of the OECD 507 guideline is questioned. Concerning possible toxicological risks of novel degradation products, future studies will have to assess potential hazards or opportunities of food processing, ultimately yielding in safer food.

Determination of human urinary metabolites of the plasticizer di(2-ethylhexyl) adipate (DEHA) by online-SPE-HPLC-MS/MS.

Di(2-ethylhexyl) adipate (DEHA) is a plasticizer and phthalate substitute used in various consumer products. Relevant population exposures have to be assumed. In this study we describe the determination of three specific side chain-oxidized monoester metabolites of DEHA, mono-2-ethyl-5-hydroxyhexyl adipate (5OH-MEHA), mono-2-ethyl-5-oxohexyl adipate (5oxo-MEHA), and mono-5-carboxy-2-ethylpentyl adipate (5cx-MEPA) in human urine as potential biomarkers of DEHA exposure. After enzymatic hydrolysis, urine samples were analyzed by online turbulent flow chromatography for matrix depletion and analyte enrichment coupled to liquid chromatography-electrospray ionization-triple quadrupole-tandem mass spectrometry (online-SPE-LC-MS/MS). For quantification stable isotope dilution was applied with limits of quantification of 0.05 µg/L for 5cx-MEPA and 5OH-MEHA, and 0.1 µg/L for 5oxo-MEHA. Method accuracies (relative recoveries) were between 92 and 109%, and relative standard deviations <5%. We investigated the applicability of the method for internal DEHA exposure assessment in six volunteers who had consumed food wrapped in commercial PVC-cling film containing DEHA and in two small pilot populations without known DEHA exposure (44 pregnant Brazilian women and 32 German adults). In the cling film experiment, we could quantify all three metabolites in all post exposure urine samples, with 5cx-MEPA being most prominent (0.30-10.2 µg/L), followed by 5OH-MEHA (0.12-4.31 µg/L) and 5oxo-MEHA (0.12-2.84 µg/L). In the Brazilian and German samples we could detect DEHA exposures in 43 and 9% of all samples, again with 5cx-MEPA as the most prominent metabolite. Based on validation and pilot biomonitoring results, the method has proven appropriate for DEHA biomonitoring and will be applied in future metabolism and population studies.

An alternative treatment method for fluorosurfactant-containing wastewater by aerosol-mediated separation.

The treatment of fluorosurfactant-containing wastewater is still challenging nowadays. Here, a method is presented to remove fluorosurfactants from water, amongst others from electroplating wastewater. This elimination technique is based on the generation of gas bubbles in solution, enrichment and scavenging of fluorosurfactants by transport of the gas bubbles to the water surface. Finally the bubbles collapse and release an aerosol which is enriched with fluorosurfactants. By sampling of the released aerosols a mass balance was established for 6:2 fluorotelomer sulfonic acid (6:2 FTSA). Thereby 99.8% of the initial amount was revocered in the collected aerosols. Fluorosurfactant concentration in solution decreased exponentially with half-lives ranging from 2 to 6 min for 6:2 FTSA as well as perfluorooctane carboxylate (PFOA) and perfluorooctane sulfonate (PFOS). Elimination rate in defined matrix (0.2 M H2SO4) within 60 min was 99.6, 99.9 and 99.8% for 6:2 FTSA, PFOA and PFOS, respectively. The removal rate of 6:2 FTSA increased in solutions with higher ionic strength. Different wastewater from an electroplating industry containing 6:2 FTSA was treated with the described method without any sample pre-treatment and elimination of 6:2 FTSA took place with the same effectiveness as in synthetic matrices.

Analysis of special surfactants by comprehensive two-dimensional gas chromatography coupled to time-of-flight mass spectrometry.

Multidimensional gas-chromatographic analyses of olesochemically based nonionic, anionic and several cationic surfactants in industrial cleaners are demonstrated. Comprehensive two-dimensional gas chromatography coupled with time-of-flight mass spectrometry allows the simultaneous determination of fatty alcohols, fatty alcohol sulphates and alkyl polyglucosides. In addition, the determination of fatty alcohol ethoxylates up to C(10)EO(8) (highest degree of ethoxylation) and C(18)EO(5) (longest C-chain at an ethoxylation degree of five) and the analysis of fatty alcohol alkoxylates that contain ethoxy (EO) and propoxy (PO) groups could be realized. Because of decomposition in the injector and a weak EI-fragmentation, cationic surfactants such as alkyl benzyl dimethyl ammonium chloride could also be identified by their characteristic fragments. Thermogravimetric analyses confirmed that the temperature in a normal GC injector is not high enough to cause thermal decomposition of esterquats. However, we could demonstrate that a modified silylation procedure forms decomposition products of esterquats in the GC injector which are detectable by GCxGC-(TOF)MS and allows the identification of such GC-atypical analytes.

Analysis of tensides in complex samples with comprehensive two-dimensional gas chromatography coupled with time-of-flight mass spectrometry.

Multidimensional gas-chromatographical analysis of various tensides of natural or synthetic origin in cosmetic products is demonstrated. Comprehensive two-dimensional gas chromatography coupled with time-of-flight mass spectrometry allows the qualitative and quantitative determination of alkyl polyglucosides (AG), fatty alcohol ethoxylates (FAEO), fatty alcohol sulfates (FAS), fatty alcohol ether sulfates (FAES) and cocamidopropyl betaines (CAPB) in shower gel and cleaning agents. The samples were aliquoted in two parts. The first part was silylated, diluted and analysed; then, in order to detect anionic tensides (FAES, FAS) too, the second aliquot was hydrolysed before being silylated for analysis. Because of their amphoteric character, the betaines can only be analysed by gas chromatography after thermal decomposition in the injector, which leads to the corresponding amidoamines among other products.

Analysis of alkyl polyglucosides in industrial products by capillary electrophoresis with pulsed amperometric detection.

Pulsed amperometric detection following micellar electrokinetic chromatography has been applied successfully to the direct detection of alkyl polyglucosides (APGs) in shampoos and other industrial products without prior conversion to highly absorbing or fluorescing derivatives. For electrochemical detection, it is necessary to dissociate the hydroxyl groups of the APGs. Thus, we used 0.1 M NaOH in the outlet vial to dissociate the APGs. The main problems associated with the combination of electrochemical detection and capillary electrophoresis are the need to isolate the detector from the electric field used in the capillary electrophoresis separation and the difficulty of aligning the working electrode with the end of the capillary. To overcome these problems, a simple capillary-electrode holder was constructed. This holder automatically aligns the capillary and the electrode in a wall-jet configuration without the aid of micropositioners and facilitates the replacement of electrodes and capillaries without reconstruction of the entire capillary/electrode setup. Special microcylindrical gold electrodes have been produced by sealing 300-microm-diameter gold wire into borosilicate-glass capillaries.