Human Observer Sensitivity to Temporal Noise During B-Mode Ultrasound Scanning: Characterization and Imaging Implications.

This work measures temporal signal-to-noise ratio (SNR) thresholds that indicate when random noise during ultrasound scanning becomes imperceptible to expert human observers. Visible noise compromises image quality and can potentially lead to non-diagnostic scans. Noise can arise from both stable acoustic sources (clutter) or randomly varying electronic sources (temporal noise). Extensive engineering effort has focused on decreasing noise in both of these categories. In this work, an observer study with five practicing sonographers was performed to assess sonographer sensitivity to temporal noise in ultrasound cine clips. Understanding the conditions where temporal noise is no longer visible during ultrasound imaging can inform engineering efforts seeking to minimize the impact this noise has on image quality. The sonographers were presented with paired temporal noise-free and noise-added simulated speckle cine clips and asked to select the noise-added clips. The degree of motion in the imaging target was found to have a significant effect on the SNR levels where noise was perceived, while changing imaging frequency had little impact. At realistic in vivo motion levels, temporal noise was not perceived in cine clips at and above 28 dB SNR. In a case study presented here, the potential of adaptive intensity adjustment based on this noise perception threshold is validated in a fetal imaging scenario. This study demonstrates how noise perception thresholds can be applied to help design or tune ultrasound systems for different imaging tasks and noise conditions.

Land surface conductance linked to precipitation: Co-evolution of vegetation and climate in Earth system models.

Vegetation and precipitation are known to fundamentally influence each other. However, this interdependence is not fully represented in climate models because the characteristics of land surface (canopy) conductance to water vapor and CO2 are determined independently of precipitation. Working within a coupled atmosphere and land modelling framework (CAM6/CLM5; coupled Community Atmosphere Model v6/Community Land Model v5), we have developed a new theoretical approach to characterizing land surface conductance by explicitly linking its dynamic properties to local precipitation, a robust proxy for moisture available to vegetation. This will enable regional surface conductance characteristics to shift fluidly with climate change in simulations, consistent with general principles of co-evolution of vegetation and climate. Testing within the CAM6/CLM5 framework shows that climate simulations incorporating the new theory outperform current default configurations across several error metrics for core output variables when measured against observational data. In climate simulations for the end of this century the new, adaptive stomatal conductance scheme provides a revised prognosis for average and extreme temperatures over several large regions, with increased primary productivity through central and east Asia, and higher rainfall through North Africa and the Middle East. The new projections also reveal more frequent heatwaves than originally estimated for the south-eastern US and sub-Saharan Africa but less frequent heatwaves across east Europe and northeast Asia. These developments have implications for evaluating food security and risks from extreme temperatures in areas that are vulnerable to climate change.

Diuretic Tolerance to Repeated-Dose Furosemide in Infants Born Very Preterm with Bronchopulmonary Dysplasia.

OBJECTIVES: To assess the presence and timing of furosemide diuretic tolerance in infants with bronchopulmonary dysplasia (BPD), and to determine if tolerance is modified by thiazide co-administration. STUDY DESIGN: We performed a retrospective cohort study among infants born very preterm with BPD exposed to repeated-dose furosemide for 72 hours, measuring net fluid balance (total intake minus total output) as a surrogate of diuresis in the 3 days before and after exposure. The primary comparison was the difference in fluid balance between the first and third 24 hours of furosemide exposure. We fit a general linear model for within-subject repeated measures of fluid balance over time, with thiazide co-administration as an interaction variable. Secondary analyses included an evaluation of weight trajectories over time. RESULTS: In 83 infants, median fluid balance ranged between + 43.6 and + 52.7 ml/kg/d in the 3 days prior to furosemide exposure. Fluid balance decreased to a median of + 29.1 ml/kg/d in the first 24 hours after furosemide, but then increased to +47.5 ml/kg/d by the third 24-hour interval, consistent with tolerance (P < .001). Thiazides did not modify the change in fluid balance during furosemide exposure for any time-period. Weight decreased significantly in the first 24 hours after furosemide and increased thereafter (P < .001). CONCLUSIONS: The net fluid balance response to furosemide decreases rapidly during repeated-dose exposures in infants with BPD, consistent with diuretic tolerance. Clinicians should consider this finding in the context of an infant's therapeutic goals. Further research efforts to identify safe and effective furosemide dosage strategies are needed.

Toward a Cenozoic history of atmospheric CO2.

The geological record encodes the relationship between climate and atmospheric carbon dioxide (CO2) over long and short timescales, as well as potential drivers of evolutionary transitions. However, reconstructing CO2 beyond direct measurements requires the use of paleoproxies and herein lies the challenge, as proxies differ in their assumptions, degree of understanding, and even reconstructed values. In this study, we critically evaluated, categorized, and integrated available proxies to create a high-fidelity and transparently constructed atmospheric CO2 record spanning the past 66 million years. This newly constructed record provides clearer evidence for higher Earth system sensitivity in the past and for the role of CO2 thresholds in biological and cryosphere evolution.

Greatly enhanced risk to humans as a consequence of empirically determined lower moist heat stress tolerance.

As heatwaves become more frequent, intense, and longer-lasting due to climate change, the question of breaching thermal limits becomes pressing. A wet-bulb temperature (Tw) of 35 °C has been proposed as a theoretical upper limit on human abilities to biologically thermoregulate. But, recent-empirical-research using human subjects found a significantly lower maximum Tw at which thermoregulation is possible even with minimal metabolic activity. Projecting future exposure to this empirical critical environmental limit has not been done. Here, using this more accurate threshold and the latest coupled climate model results, we quantify exposure to dangerous, potentially lethal heat for future climates at various global warming levels. We find that humanity is more vulnerable to moist heat stress than previously proposed because of these lower thermal limits. Still, limiting warming to under 2 °C nearly eliminates exposure and risk of widespread uncompensable moist heatwaves as a sharp rise in exposure occurs at 3 °C of warming. Parts of the Middle East and the Indus River Valley experience brief exceedances with only 1.5 °C warming. More widespread, but brief, dangerous heat stress occurs in a +2 °C climate, including in eastern China and sub-Saharan Africa, while the US Midwest emerges as a moist heat stress hotspot in a +3 °C climate. In the future, moist heat extremes will lie outside the bounds of past human experience and beyond current heat mitigation strategies for billions of people. While some physiological adaptation from the thresholds described here is possible, additional behavioral, cultural, and technical adaptation will be required to maintain healthy lifestyles.

Echocardiographic Assessment of Pulmonary Arterial Hypertension Following Inhaled Nitric Oxide in Infants with Severe Bronchopulmonary Dysplasia.

OBJECTIVES: Inhaled nitric oxide (iNO) is an effective pulmonary vasodilator. However, the efficacy of iNO in former premature infants with established bronchopulmonary dysplasia (BPD) has not been studied. This study aimed to determine the efficacy of iNO in reducing pulmonary artery pressure in infants with severe BPD as measured by echocardiography. STUDY DESIGN: Prospective, observational study enrolling infants born at less than 32 weeks gestation and in whom (1) iNO therapy was initiated after admission to our institution, or (2) at the outside institution less than 48 h before transfer and received an echocardiogram prior to iNO initiation, and (3) had severe BPD. Data were collected at three time-points: (1) before iNO; (2) 12-48 h after initiation of iNO; and (3) 48-168 h after initiation of iNO. The primary outcome was the effect of iNO on pulmonary artery pressure measured by echocardiography in patients with severe BPD between 48 and 168 h after initiating iNO therapy. RESULTS: Of 37 enrolled, 81% had echocardiographic evidence of pulmonary arterial hypertension (PAH) before iNO and 56% after 48 h of iNO (p = 0.04). FiO2 requirements were significantly different between time-points (1) and (3) (p = 0.05). There were no significant differences between Tricuspid Annular Plane Systolic Excursion (TAPSE) Z-Scores, time to peak velocity: right ventricular ejection time (TPV:RVET), and ventilator changes. CONCLUSIONS: Although we found a statistically significant reduction of PAH between time-point (1) and (3), future trials are needed to further guide clinical care.

Impact of COVID-19 on Infants followed after Discharge from the Neonatal Intensive Care Unit Using a Telemedicine Model.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) continues to have a profound impact on infant health care and health outcomes. In this study, we aimed to characterize the social impact of the first COVID-19 lockdown on families in a neonatal follow-up program (NFP). Given the ongoing increased use of telehealth across the medicine, we also evaluated for patient-level differences in virtual visit rates to identify patients at risk of follow-up challenges. STUDY DESIGN: To assess the impact of virtual health care utilization, we conducted a retrospective cohort study to describe challenges associated with telemedicine use in this vulnerable patient population during our telemedicine epoch (March 13, 2020-July 31, 2020). We also looked for patient-level factors associated with attending NFP visits as scheduled. Finally, we summarized caregiver responses to a COVID-19 Obstacles Assessment Survey and assessed for racial disparities in these responses. RESULTS: When comparing patients who completed their virtual visit to those who did not, we found no differences by infants' sex, birthweight, gestational age at birth, or caregiver self-reported race and ethnicity. However, infants whose visits did not occur were more often discharged with equipment or covered by public insurance. Nine percent of families reported food insecurity. CONCLUSION: During the initial COVID-19 lockdown, families with infants discharged from a neonatal intensive care unit (NICU) faced significant obstacles caring for their infants and attending scheduled follow-up visits. Infants in families with lower socioeconomic status or with increased medical complexity faced increased challenges in attending virtual follow-up visits during this epoch. Given the ongoing reliance on telemedicine in health care and the need to better prepare for future epidemics/pandemics, this study offers critical information that can assist neonatal teams in bolstering transitions to home and creating stronger safety nets for their patients after discharge. KEY POINTS: · Telemedicine works well for high-risk neonatal populations.. · Infant medical complexity may be a risk factor for challenges attending neonatal follow-up visits.. · NICUs should work to prevent food insecurity postdischarge..

Persistent high latitude amplification of the Pacific Ocean over the past 10 million years.

While high latitude amplification is seen in modern observations, paleoclimate records, and climate modeling, better constraints on the magnitude and pattern of amplification would provide insights into the mechanisms that drive it, which remain actively debated. Here we present multi-proxy multi-site paleotemperature records over the last 10 million years from the Western Pacific Warm Pool (WPWP) - the warmest endmember of the global ocean that is uniquely important in the global radiative feedback change. These sea surface temperature records, based on lipid biomarkers and seawater Mg/Ca-adjusted foraminiferal Mg/Ca, unequivocally show warmer WPWP in the past, and a secular cooling over the last 10 million years. Compiling these data with existing records reveals a persistent, nearly stationary, extratropical response pattern in the Pacific in which high latitude (~50°N) temperatures increase by ~2.4° for each degree of WPWP warming. This relative warming pattern is also evident in model outputs of millennium-long climate simulations with quadrupling atmospheric CO2, therefore providing a strong constraint on the future equilibrium response of the Earth System.

Left Atrial Strain and the Risk of Atrial Arrhythmias From Extended Ambulatory Cardiac Monitoring: MESA.

Background Abnormalities in left atrial (LA) function often occur before LA structural changes and clinically identified atrial fibrillation (AF). Little is known about the relationship between LA strain and the risk of subclinical atrial arrhythmias detected from extended ambulatory cardiac monitoring. Methods and Results A total of 1441 participants of MESA (Multi-Ethnic Study of Atherosclerosis) completed speckle-tracking echocardiography and cardiac monitoring during 2016 to 2018 (mean age, 73 years); participants in AF during echocardiography or during the entire cardiac monitoring period were excluded. Absolute values of LA reservoir, booster pump, and conduit strains were measured. We evaluated associations of LA strain with monitor-detected AF, premature atrial contractions, and supraventricular tachycardia. Primary analyses adjusted for demographic variables, blood pressure, diabetes, smoking, and clinical cardiovascular disease. Cardiac monitoring (median, 14 days) detected AF in 3%. Each SD (4.0%) lower (worse) LA booster pump strain was associated with 84% higher risk of monitor-detected AF (95% CI, 30%-162%), 39% higher premature atrial contraction frequency (95% CI, 27%-53%), and 19% higher supraventricular tachycardia frequency (95% CI, 10%-29%). Additional adjustment for NT-proBNP (N-terminal pro-B-type natriuretic peptide), LA volume index, tissue Doppler a' peak velocity, left ventricular ejection fraction, and global longitudinal strain had little impact on associations. Findings were similar for LA reservoir strain and null for LA conduit strain. Conclusions In a multiethnic community-based cohort, impaired LA strain was an important correlate of subclinical atrial arrhythmias, even after adjustment for conventional measures of LA structure and function.

African Hydroclimate During the Early Eocene From the DeepMIP Simulations.

The early Eocene (∼56-48 Myr ago) is characterized by high CO2 estimates (1,200-2,500 ppmv) and elevated global temperatures (∼10°C-16°C higher than modern). However, the response of the hydrological cycle during the early Eocene is poorly constrained, especially in regions with sparse data coverage (e.g., Africa). Here, we present a study of African hydroclimate during the early Eocene, as simulated by an ensemble of state-of-the-art climate models in the Deep-time Model Intercomparison Project (DeepMIP). A comparison between the DeepMIP pre-industrial simulations and modern observations suggests that model biases are model- and geographically dependent, however, these biases are reduced in the model ensemble mean. A comparison between the Eocene simulations and the pre-industrial suggests that there is no obvious wetting or drying trend as the CO2 increases. The results suggest that changes to the land sea mask (relative to modern) in the models may be responsible for the simulated increases in precipitation to the north of Eocene Africa. There is an increase in precipitation over equatorial and West Africa and associated drying over northern Africa as CO2 rises. There are also important dynamical changes, with evidence that anticyclonic low-level circulation is replaced by increased south-westerly flow at high CO2 levels. Lastly, a model-data comparison using newly compiled quantitative climate estimates from paleobotanical proxy data suggests a marginally better fit with the reconstructions at lower levels of CO2.

Comparison of knowledge acquisition and retention following traditional didactic vs. flipped classroom education utilizing a standardized national curriculum: a randomized controlled trial.

OBJECTIVE: Measure the effectiveness of and preference for a standardized, national curriculum utilizing flipped classrooms (FC) in neonatal-perinatal medicine (NPM) fellowships. STUDY DESIGN: Multicentered equivalence, cluster randomized controlled trial of NPM fellowship programs randomized to receive standardized physiology education as in-class lectures (traditional didactic, TD arm) or as pre-class online videos followed by in-class discussions (FC arm). Four multiple-choice question quizzes and three surveys were administered to measure knowledge acquisition, retention, and educational preferences. RESULTS: 530 fellows from 61 NPM fellowships participated. Quiz performance was comparable between groups at all time points (p = NS, TD vs FC at 4 time points). Post intervention, more fellows in both groups preferred group discussions (pre/post FC 42% vs. 58%, P = 0.002; pre/post TD 43% vs. 60%, P = < 0.001). FC fellows were more likely to rate classroom effectiveness positively (FC/TD, 70% vs. 36%, P < 0.001). CONCLUSIONS: FCs promote knowledge acquisition and retention equivalent to TD and FC modalities are preferred by fellows.

An Automated Region-Selection Method for Adaptive ALARA Ultrasound Imaging.

The objective of this work was to develop an automated region of the interest selection method to use for adaptive imaging. The as low as reasonably achievable (ALARA) principle is the recommended framework for setting the output level of diagnostic ultrasound devices, but studies suggest that it is not broadly observed. One way to address this would be to adjust output settings automatically based on image quality feedback, but a missing link is determining how and where to interrogate the image quality. This work provides a method of region of interest selection based on standard, envelope-detected image data that are readily available on ultrasound scanners. Image brightness, the standard deviation of the brightness values, the speckle signal-to-noise ratio, and frame-to-frame correlation were considered as image characteristics to serve as the basis for this selection method. Region selection with these filters was compared to results from image quality assessment at multiple acoustic output levels. After selecting the filter values based on data from 25 subjects, testing on ten reserved subjects' data produced a positive predictive value of 94% using image brightness, the speckle signal-to-noise ratio, and frame-to-frame correlation. The best case filter values for using only image brightness and speckle signal-to-noise ratio had a positive predictive value of 97%. These results suggest that these simple methods of filtering could select reliable regions of interest during live scanning to facilitate adaptive ALARA imaging.

The latitudinal temperature gradient and its climate dependence as inferred from foraminiferal δ18O over the past 95 million years.

SignificanceThe temperature difference between low and high latitudes is one measure of the efficiency of the global climate system in redistributing heat and is used to test the ability of models to represent the climate system through time. Here, we show that the latitudinal temperature gradient has exhibited a consistent inverse relationship with global mean sea-surface temperature for at least the past 95 million years. Our results help reduce conflicts between climate models and empirical estimates of temperature and argue for a fundamental consistency in the dynamics of heat transport and radiative transfer across vastly different background states.

Health Care Professional and Caregiver Attitudes Toward and Usage of Medical Podcasting: Questionnaire Study.

BACKGROUND: Podcasts are used increasingly in medicine. There is growing research into the role of podcasts in medical education, but the use of podcasting as a tool for pediatric parent/caregiver health education is largely unexplored. As parents/caregivers seek medical information online, an understanding of parental preferences is needed. OBJECTIVE: We sought to explore health care professional and parent/caregiver awareness and views on podcasting as a health education tool. METHODS: This survey study was conducted and distributed via in-person collection from parents/caregivers (≥18 years old) in the waiting room of an academic pediatric primary care clinic, targeted social media promotion, and professional listservs for health care professionals in pediatrics. Statistical analysis included chi-square tests of independence between categorical variables. RESULTS: In total, 125 health care professionals and 126 caregivers completed the survey. Of those surveyed, 81% (101/125) of health care professionals and 55% (69/126) of parents/caregivers listened to podcasts (P<.001). Health care professionals and parents/caregivers listed the same top 3 quality indicators for medical podcasts. Podcast listeners were more likely to have higher incomes and use professional websites for information. The survey elicited a variety of reasons for podcast nonengagement. CONCLUSIONS: Health care professionals appear to be more engaged in medical education podcasts than parents/caregivers. However, similar factors were valued when evaluating the quality of a pediatric podcast: accuracy, transparency, and credibility. Professional websites may be one avenue to increase podcast uptake. More needs to be done to explore the use of podcasts and digital media for medical information.

Occult Regions of Suppressed Coherence in Liver B-Mode Images.

Ultrasound is an essential tool for diagnosing and monitoring diseases, but it can be limited by poor image quality. Lag-one coherence (LOC) is an image quality metric that can be related to signal-to-noise ratio and contrast-to-noise ratio. In this study, we examine matched LOC and B-mode images of the liver to discern patterns of low image quality, as indicated by lower LOC values, occurring beneath the abdominal wall, near out-of-plane vessels and adjacent to hyperechoic targets such the liver capsule. These regions of suppressed coherence are often occult; they present as temporally stable uniform speckle on B-mode images, but the LOC measurements in these regions suggest substantially degraded image quality. Quantitative characterization of the coherence suppression beneath the abdominal wall reveals a consistent pattern both in simulations and in vivo; sharp drops in coherence occurring beneath the abdominal wall asymptotically recover to a stable coherence at depth. Simulation studies suggest that abdominal wall reverberation clutter contributes to the initial drop in coherence but does not influence the asymptotic LOC value. Clinical implications are considered for contrast loss in B-mode imaging and estimation errors for elastography and Doppler imaging.

Does Chronic Use of High Dose Proton Pump Inhibitors Increase Risk for Pancreatic Cancer?

OBJECTIVES: To analyze whether use of proton pump inhibitors increase the risk for pancreatic cancer in a mouse model and human clinical cohorts. METHODS: p48-Cre/LSL-KrasG12D mice that develop precancerous pancreatic intraepithelial neoplasia (PanINs) were treated with low- or high-dose proton pump inhibitors (PPIs) orally for 1 and 4 months. The mechanism for the cholecystokinin receptor 2 (CCK-2R) activation was investigated in vitro. Two resources were employed to analyze the risk of pancreatic cancer in human subjects with PPI use. RESULTS: Serum gastrin levels were increased 8-fold (P < 0.0001) in mice treated with chronic high-dose PPIs, and this change correlated with an increase (P = 0.02) in PanIN grade and the development of microinvasive cancer. The CCK-2R expression was regulated by microRNA-148a in the p48-Cre/LSL-KrasG12D mice pancreas and in human pancreatic cancer cells in vitro. Proton pump inhibitor consumption in human subjects was correlated with pancreatic cancer risk (odds ratio, 1.54). A validation analysis conducted using the large-scale United Kingdom Biobank database confirmed the correlation (odds ratio, 1.9; P = 0.00761) of pancreatic cancer risk with PPI exposure. CONCLUSIONS: This investigation revealed in both murine models and human subjects, PPI use is correlated with a risk for development of pancreatic cancer.

Achieving adequate growth in infants with congenital diaphragmatic hernia prior to discharge.

BACKGROUND/PURPOSE: To evaluate the enteral feeding requirements, including caloric provisions, of infants with CDH in relation to growth patterns. METHODS: A retrospective observational study was conducted on infants with CDH between August 2012 and March 2017. Electronic medical records were reviewed to extract detailed infant feeding data and anthropometric measurements at monthly intervals until discharge. Statistical methods of analysis included generalized linear models, Pearson correlation coefficient, Analysis of variance (ANOVA), Kruskal-Wallis, Wilcoxon rank sum, and Fisher's Exact tests. RESULTS: Among 149 infants with CDH, 45% (n = 67) met criteria for malnutrition at discharge. Maternal human milk (HM) was initiated in 95% of infants (n = 142) and continued in 79% of infants (n = 118) at discharge. Overall, 50% received fortification of feeds, including 60% (n = 89) of formula fed infants compared to only 21% (n = 31) of HM fed infants (p<0.001). Infants fed formula had lower weight-for-length z-scores at discharge compared to those fed HM. CONCLUSIONS: Infants receiving HM demonstrated improved growth compared to formula fed infants. However, higher calorie feeding regimens need to be initiated earlier to improve growth velocity. Prompt recognition of malnutrition and growth failure with aggressive supplementation may improve the overall growth of infants with CDH and has the potential to improve long term neurodevelopmental outcomes.

Delivery room oxygen physiology and respiratory interventions for newborns with cyanotic congenital heart disease.

OBJECTIVE: To characterize pulse oxygen saturation (SpO2) trajectories and respiratory interventions after birth for newborns with cyanotic congenital heart disease (CCHD). STUDY DESIGN: Retrospective single-site study of newborns ≥32 weeks gestation with CCHD: single ventricle with critical aortic obstruction (SV-CAO), critical pulmonic obstruction (CPO), transposition of the great arteries (TGA). Minute-to-minute SpO2 values and respiratory interventions were summarized and compared. RESULTS: Two hundred infants were enrolled. SpO2 at each minute differed across groups (p < 0.01), with the lowest values in TGA. All interventions were most frequent in TGA (p < 0.01). Continuous positive airway pressure was provided in 22% SV-CAO, 23% CPO, and 66% TGA. Positive pressure ventilation occurred in 7% SV-CAO, 14% CPO, and 33% TGA. Intubation occurred in 4% SV-CAO, 10% CPO, and 53% TGA. CONCLUSION: We defined SpO2 trajectories and delivery room respiratory interventions for three CCHD phenotypes. These results inform delivery room management of these high-risk populations.

Association Between Kidney Clearance of Secretory Solutes and Cardiovascular Events: The Chronic Renal Insufficiency Cohort (CRIC) Study.

RATIONALE & OBJECTIVE: The clearance of protein-bound solutes by the proximal tubules is an innate kidney mechanism for removing putative uremic toxins that could exert cardiovascular toxicity in humans. However, potential associations between impaired kidney clearances of secretory solutes and cardiovascular events among patients with chronic kidney disease (CKD) remains uncertain. STUDY DESIGN: A multicenter, prospective, cohort study. SETTING & PARTICIPANTS: We evaluated 3,407 participants from the Chronic Renal Insufficiency Cohort (CRIC) study. EXPOSURES: Baseline kidney clearances of 8 secretory solutes. We measured concentrations of secretory solutes in plasma and paired 24-hour urine specimens using liquid chromatography-tandem mass spectrometry (LC-MS/MS). OUTCOMES: Incident heart failure, myocardial infarction, and stroke events. ANALYTICAL APPROACH: We used Cox regression to evaluate associations of baseline secretory solute clearances with incident study outcomes adjusting for estimated GFR (eGFR) and other confounders. RESULTS: Participants had a mean age of 56 years; 45% were women; 41% were Black; and the median estimated glomerular filtration rate (eGFR) was 43 mL/min/1.73 m2. Lower 24-hour kidney clearance of secretory solutes were associated with incident heart failure and myocardial infarction but not incident stroke over long-term follow-up after controlling for demographics and traditional risk factors. However, these associations were attenuated and not statistically significant after adjustment for eGFR. LIMITATIONS: Exclusion of patients with severely reduced eGFR at baseline; measurement variability in secretory solutes clearances. CONCLUSIONS: In a national cohort study of CKD, no clinically or statistically relevant associations were observed between the kidney clearances of endogenous secretory solutes and incident heart failure, myocardial infarction, or stroke after adjustment for eGFR. These findings suggest that tubular secretory clearance provides little additional information about the development of cardiovascular disease events beyond glomerular measures of GFR and albuminuria among patients with mild-to-moderate CKD.

Goals of Care Discussions and Moral Distress Among Neonatal Intensive Care Unit Staff.

CONTEXT: The relationship between quality of Goals of Care (GOC) conversations and moral distress among neonatal intensive care unit (NICU) providers is not known. OBJECTIVES: We sought 1) to explore levels of moral distress in providers, 2) to evaluate how staff moral distress changes in relation to GOC discussions, and 3) to identify elements of GOC discussions associated with change in moral distress. We hypothesized that staff moral distress would change after GOC discussions and that change would vary with presence of key discussion elements. METHODS: Prospective cohort study in a level IV NICU in an urban teaching hospital. We administered validated instruments at baseline and following GOC discussions including the Moral Distress Thermometer (MDT) and Williams Instrument (a measure of end-of-life care) to physicians, nurses, and social workers. RESULTS: We collected data on 79 GOC conversations over a 1-year period from 2018 to 2019. Most providers experienced an increase in moral distress following a GOC discussion. Providers experienced an average increase in moral distress, as measured by the MDT, of 0.84 (+/-3.15; P = 0.002). Physicians experienced an average change in moral distress of 1.1 (+/-3.52; P = 0.01) while nurses experienced an average change of 0.55 (+/-2.66; P = 0.07). Several elements of discussions were associated with the degree of increase in moral distress after the conversation. CONCLUSION: Change in moral distress among providers may be a useful metric of quality of GOC discussions. There are identifiable elements of GOC conversations that are associated with high-quality discussions. These elements warrant further study.