Strong future increases in Arctic precipitation variability linked to poleward moisture transport

The Arctic region is projected to experience amplified warming as well as strongly increasing precipitation rates. Equally important to trends in the mean climate are changes in interannual variability, but changes in precipitation fluctuations are highly uncertain and the associated processes are unknown. Here, we use various state-of-the-art global climate model simulations to show that interannual variability of Arctic precipitation will likely increase markedly (up to 40% over the 21st century), especially in summer. This can be attributed to increased poleward atmospheric moisture transport variability associated with enhanced moisture content, possibly modulated by atmospheric dynamics. Because both the means and variability of Arctic precipitation will increase, years/seasons with excessive precipitation will occur more often, as will the associated impacts

Transcatheter edge-to-edge repair of tricuspid regurgitation in the Netherlands:state of the art and future perspectives

Despite the high prevalence and adverse clinical outcomes of severe tricuspid regurgitation (TR), conventional treatment options, surgical or pharmacological, are limited. Surgery is associated with a high peri-operative risk and medical treatment has not clearly resulted in clinical improvements. Therefore, there is a high unmet need to reduce morbidity and mortality in patients with severe TR. During recent years, several transcatheter solutions have been studied. This review focuses on the transcatheter edge-to-edge repair of TR (TTVR) with respect to patient selection, the procedure, pre- and peri-procedural echocardiographic assessments and clinical outcomes. Furthermore, we highlight the current status of TTVR in the Netherlands and provide data from our initial experience at the University Medical Centre Groningen

Attribution of the Australian bushfire risk to anthropogenic climate change

Disastrous bushfires during the last months of 2019 and January 2020 affected Australia, raising the question to what extent the risk of these fires was exacerbated by anthropogenic climate change. To answer the question for southeastern Australia, where fires were particularly severe, affecting people and ecosystems, we use a physically based index of fire weather, the Fire Weather Index; long-term observations of heat and drought; and 11 large ensembles of state-of-the-art climate models. We find large trends in the Fire Weather Index in the fifth-generation European Centre for Medium-Range Weather Forecasts (ECMWF) Atmospheric Reanalysis (ERA5) since 1979 and a smaller but significant increase by at least 30 % in the models. Therefore, we find that climate change has induced a higher weather-induced risk of such an extreme fire season. This trend is mainly driven by the increase of temperature extremes. In agreement with previous analyses we find that heat extremes have become more likely by at least a factor of 2 due to the long-term warming trend. However, current climate models overestimate variability and tend to underestimate the long-term trend in these extremes, so the true change in the likelihood of extreme heat could be larger, suggesting that the attribution of the increased fire weather risk is a conservative estimate. We do not find an attributable trend in either extreme annual drought or the driest month of the fire season, September–February. The observations, however, show a weak drying trend in the annual mean. For the 2019/20 season more than half of the July–December drought was driven by record excursions of the Indian Ocean Dipole and Southern Annular Mode, factors which are included in the analysis here. The study reveals the complexity of the 2019/20 bushfire event, with some but not all drivers showing an imprint of anthropogenic climate change. Finally, the study concludes with a qualitative review of various vulnerability and exposure factors that each play a role, along with the hazard in increasing or decreasing the overall impact of the bushfires

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation.

OBJECTIVES: To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. DESIGN: The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA2DS2-VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). PARTICIPANTS: Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. RESULTS: The discriminatory value of the GARFIELD-AF risk model was superior to CHA2DS2-VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to 0.78), 0.69 (0.67 to 0.71) and 0.66 (0.62 to 0.69), respectively, for the GARFIELD-AF risk models, and 0.66 (0.64-0.67), 0.64 (0.61-0.66) and 0.64 (0.61-0.68), respectively, for CHA2DS2-VASc (or HAS-BLED for bleeding). In very low to low risk patients (CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)), the CHA2DS2-VASc and HAS-BLED (for bleeding) scores offered weak discriminatory value for mortality, stroke/systemic embolism and major bleeding. C-statistics for the GARFIELD-AF risk tool were 0.69 (0.64 to 0.75), 0.65 (0.56 to 0.73) and 0.60 (0.47 to 0.73) for each end point, respectively, versus 0.50 (0.45 to 0.55), 0.59 (0.50 to 0.67) and 0.55 (0.53 to 0.56) for CHA2DS2-VASc (or HAS-BLED for bleeding). Upon validation in the ORBIT-AF population, C-statistics showed that the GARFIELD-AF risk tool was effective for predicting 1-year all-cause mortality using the full and simplified model for all-cause mortality: C-statistics 0.75 (0.73 to 0.77) and 0.75 (0.73 to 0.77), respectively, and for predicting for any stroke or systemic embolism over 1 year, C-statistics 0.68 (0.62 to 0.74). CONCLUSIONS: Performance of the GARFIELD-AF risk tool was superior to CHA2DS2-VASc in predicting stroke and mortality and superior to HAS-BLED for bleeding, overall and in lower risk patients. The GARFIELD-AF tool has the potential for incorporation in routine electronic systems, and for the first time, permits simultaneous evaluation of ischaemic stroke, mortality and bleeding risks. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF (NCT01090362) and for ORBIT-AF (NCT01165710)

Two-year outcomes of patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF.

AIMS: The relationship between outcomes and time after diagnosis for patients with non-valvular atrial fibrillation (NVAF) is poorly defined, especially beyond the first year. METHODS AND RESULTS: GARFIELD-AF is an ongoing, global observational study of adults with newly diagnosed NVAF. Two-year outcomes of 17 162 patients prospectively enrolled in GARFIELD-AF were analysed in light of baseline characteristics, risk profiles for stroke/systemic embolism (SE), and antithrombotic therapy. The mean (standard deviation) age was 69.8 (11.4) years, 43.8% were women, and the mean CHA2DS2-VASc score was 3.3 (1.6); 60.8% of patients were prescribed anticoagulant therapy with/without antiplatelet (AP) therapy, 27.4% AP monotherapy, and 11.8% no antithrombotic therapy. At 2-year follow-up, all-cause mortality, stroke/SE, and major bleeding had occurred at a rate (95% confidence interval) of 3.83 (3.62; 4.05), 1.25 (1.13; 1.38), and 0.70 (0.62; 0.81) per 100 person-years, respectively. Rates for all three major events were highest during the first 4 months. Congestive heart failure, acute coronary syndromes, sudden/unwitnessed death, malignancy, respiratory failure, and infection/sepsis accounted for 65% of all known causes of death and strokes for <10%. Anticoagulant treatment was associated with a 35% lower risk of death. CONCLUSION: The most frequent of the three major outcome measures was death, whose most common causes are not known to be significantly influenced by anticoagulation. This suggests that a more comprehensive approach to the management of NVAF may be needed to improve outcome. This could include, in addition to anticoagulation, interventions targeting modifiable, cause-specific risk factors for death. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Modelling the re-intensification of tropical storm Erin (2007) over Oklahoma: understanding the key role of downdraft formulation

This article reports on the inland re-intensification of tropical storm (TS) Erin (2007). In this research, the physical processes that resulted in the re-intensification of TS Erin over Oklahoma, USA, on 19 August 2007 was determined and a sensitivity study on microphysics, planetary boundary layer and convective parameterisation schemes was performed in the mesoscale modelling system, MM5. Also, we diagnosed and explained the remarkable difference between model behaviour of the original KainFritsch 1 (KF1) scheme and its revised counterpart (KF2). The numerical results showed only modest sensitivity to the selected microphysics schemes the relatively simple ‘Simple Ice’ and the advanced Reisner-Graupel. We found a relatively high sensitivity to the selected boundary layer parameterisation. Enhanced mixing in the medium range forecast (MRF) scheme leads to a relatively small convective available potential energy (CAPE), a deeper boundary layer and a lower dew point temperature, thus to a relatively stable environment. Therefore, MRF forecasts less precipitation (up to 150 mm) than the local mixing scheme, ETA. Model results appeared most sensitive to the selected convection schemes, that is, Grell, KF1 and KF2. With Grell and KF1, Erin intensifies and produces intense precipitation, but its structure remains close to a mesoscale convective system (MCS) or squall line rather than of the observed tropical cyclone. Both schemes also simulate the most intense precipitation too far south (100 km) compared to observations. On the contrary, KF2 underestimates precipitation, but the track of the convection, the precipitation and the pressure distribution are relatively close to radar and field observations. A sensitivity study reveals that the downdraft formulation is critical to modelling TS Erin’s dynamics. Within tropical cyclogenesis, the mid-level relative humidity (RH) is generally very high, resulting in very small downdrafts. KF2 generates hardly any downdrafts due to its dependence on mid-level RH. However, KF1 and Grell generate much stronger downdrafts because they both relate the downdraft mass flux (DMF) to vertical wind shear. This larger DMF then completely alters TS Erin’s dynamics. A modified version of the Grell scheme with KF2 RH-dependent downdraft formulation improved the simulation considerably, with better resemblance to observations on trajectory, radar reflectivity and system structure