Steven K. Krueger

Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial

BACKGROUND Results of previous studies support the hypothesis that implantable haemodynamic monitoring systems might reduce rates of hospitalisation in patients with heart failure. We undertook a single-blind trial to assess this approach. METHODS Patients with New York Heart Association (NYHA) class III heart failure, irrespective of the left ventricular ejection fraction, and a previous hospital admission for heart failure were enrolled in 64 centres in the USA. They were randomly assigned by use of a centralised electronic system to management with a wireless implantable haemodynamic monitoring (W-IHM) system (treatment group) or to a control group for at least 6 months. Only patients were masked to their assignment group. In the treatment group, clinicians used daily measurement of pulmonary artery pressures in addition to standard of care versus standard of care alone in the control group. The primary efficacy endpoint was the rate of heart-failure-related hospitalisations at 6 months. The safety endpoints assessed at 6 months were freedom from device-related or system-related complications (DSRC) and freedom from pressure-sensor failures. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00531661. FINDINGS In 6 months, 83 heart-failure-related hospitalisations were reported in the treatment group (n=270) compared with 120 in the control group (n=280; rate 0·31 vs 0·44, hazard ratio [HR] 0·70, 95% CI 0·60-0·84, p<0·0001). During the entire follow-up (mean 15 months [SD 7]), the treatment group had a 39% reduction in heart-failure-related hospitalisation compared with the control group (153 vs 253, HR 0·64, 95% CI 0·55-0·75; p<0·0001). Eight patients had DSRC and overall freedom from DSRC was 98·6% (97·3-99·4) compared with a prespecified performance criterion of 80% (p<0·0001); and overall freedom from pressure-sensor failures was 100% (99·3-100·0). INTERPRETATION Our results are consistent with, and extend, previous findings by definitively showing a significant and large reduction in hospitalisation for patients with NYHA class III heart failure who were managed with a wireless implantable haemodynamic monitoring system. The addition of information about pulmonary artery pressure to clinical signs and symptoms allows for improved heart failure management. FUNDING CardioMEMS.

Rain in shallow cumulus over the ocean: the RICO Campaign

Shallow, maritime cumuli are ubiquitous over much of the tropical oceans, and characterizing their properties is important to understanding weather and climate. The Rain in Cumulus over the Ocean (RICO) field campaign, which took place during November 2004–January 2005 in the trades over the western Atlantic, emphasized measurements of processes related to the formation of rain in shallow cumuli, and how rain subsequently modifies the structure and ensemble statistics of trade wind clouds. Eight weeks of nearly continuous S-band polarimetric radar sampling, 57 flights from three heavily instrumented research aircraft, and a suite of ground- and ship-based instrumentation provided data on trade wind clouds with unprecedented resolution. Observational strategies employed during RICO capitalized on the advances in remote sensing and other instrumentation to provide insight into processes that span a range of scales and that lie at the heart of questions relating to the cause and effects of rain from shallow ...

Left Ventricular Assist Device as Destination for Patients Undergoing Intravenous Inotropic Therapy: A Subset Analysis From REMATCH (Randomized Evaluation of Mechanical Assistance in Treatment of Chronic Heart Failure)

Background—Left ventricular assist devices (LVADs) have improved survival in patients with end-stage heart failure. Compared with previous trials, the Randomized Evaluation of Mechanical Assistance in Treatment of Chronic Heart Failure (REMATCH) trial enrolled patients with more advanced heart failure and high prevalence of intravenous inotropic therapy. This study analyzes, on a post hoc basis, outcomes in patients undergoing inotropic infusions at randomization. Methods and Results—Of 129 patients randomized, 91 were receiving intravenous inotropic therapy at randomization to LVAD or optimal medical management (OMM). Mean systolic pressure was 100 versus 107 mm Hg in those not receiving inotropes, serum sodium was 134 versus 137 mEq/L, and left ventricular ejection fraction was 17% for both groups. LVADs improved survival throughout follow-up for patients undergoing baseline inotropic infusions (P=0.0014); for the LVAD group versus the OMM group, respectively, 6-month survival was 60% versus 39%, 1-year survival rates were 49% versus 24%, and 2-year survival rates were 28% versus 11%. For 38 patients not undergoing inotropic infusions, 6-month survival was 61% for those with LVADs and 67% for those with OMM, whereas 1-year rates were 57% and 40%, respectively (P=0.55). Quality-of-life scores for survivors improved. Median days out of hospital for patients on inotropic therapy at randomization were 255 with LVAD and 105 with OMM. Conclusions—Despite severe compromise, patients undergoing inotropic infusions at randomization derived major LVAD survival benefit with improved quality of life. Patients not undergoing inotropic infusions had higher survival rates both with and without LVAD, but differences did not reach significance. Future studies should prespecify analyses of inotropic and other therapies to determine how disease severity and parallel medical treatment influence the benefits offered by mechanical circulatory support.

An intercomparison of cloud-resolving models with the atmospheric radiation measurement summer 1997 intensive observation period data

SUMMARY This paper reports an intercomparison study of midlatitude continental cumulus convection simulated by eight two-dimensional and twothree-dimensional cloud-resolving models (CRMs), driven by observed large-scale advective temperature and moisture tendencies, surface turbulent euxes, and radiative-heating proe les during three sub-periods of the summer 1997 Intensive Observation Period of the US Department of Energy’s Atmospheric Radiation Measurement (ARM) program. Each sub-period includes two or three precipitation events of various intensities over a span of 4 or 5 days. The results can be summarized as follows. CRMs can reasonably simulate midlatitude continental summer convection observed at the ARM Cloud and Radiation Testbed site in terms of the intensity of convective activity, and the temperature and specie c-humidity evolution. Delayed occurrences of the initial precipitation events are a common feature for all three sub-cases among the models. Cloud mass e uxes, condensate mixing ratios and hydrometeor fractions produced by all CRMs are similar. Some of the simulated cloud properties such as cloud liquid-water path and hydrometeor fraction are rather similar to available observations. All CRMs produce large downdraught mass euxes with magnitudes similar to those of updraughts, in contrast to CRM results for tropical convection. Some inter-model differences in cloud properties are likely to be related to those in the parametrizations of microphysical processes. There is generally a good agreement between the CRMs and observations with CRMs being signie cantly better than single-column models (SCMs), suggesting that current results are suitable for use in improving parametrizations in SCMs. However, improvements can still be made in the CRM simulations; these include the proper initialization of the CRMs and a more proper method of diagnosing cloud boundaries in model outputs for comparison with satellite and radar cloud observations.

Evaluation of cloudiness parameterizations using a cumulus ensemble model

Abstract Diagnostic cloudiness parameterizations in large-scale models are evaluated by using a two-dimensional numerical cumulus ensemble model. The model covers a large horizontal domain (512 km) but resolves individual clouds. This study explores the dependence of diagnostic relations (between cloud amount and a large-scale variable) on cloud regime, horizontal averaging distance, and cloud type for tropical convective cloud regimes. Large-scale variables, including relative humidity, cumulus mass flux, large-scale vertical velocity and surface precipitation rate, are examined. It is shown that the total cloud amount can be better estimated as the sum of separate estimates of stratiform and convective cloud amounts using different large-scale variables than by an estimate of the total cloud amount using any single large-scale variable. The stratiform cloud amount can best be estimated by using relative humidity. The convective cloud amount can be diagnosed by using cumulus mass flux. Neither set of dia...

Large-Eddy Simulations of a Drizzling, Stratocumulus-Topped Marine Boundary Layer

Cloud water sedimentation and drizzle in a stratocumulus-topped boundary layer are the focus of an intercomparison of large-eddy simulations. The context is an idealized case study of nocturnal stratocumulus under a dry inversion, with embedded pockets of heavily drizzling open cellular convection. Results from 11 groups are used. Two models resolve the size distributions of cloud particles, and the others parameterize cloud water sedimentation and drizzle. For the ensemble of simulations with drizzle and cloud water sedimentation, the mean liquid water path (LWP) is remarkably steady and consistent with the measurements, the mean entrainment rate is at the low end of the measured range, and the ensemble-average maximum vertical wind variance is roughly half that measured. On average, precipitation at the surface and at cloud base is smaller, and the rate of precipitation evaporation greater, than measured. Including drizzle in the simulations reduces convective intensity, increases boundary layer stratification, and decreases LWP for nearly all models. Including cloud water sedimentation substantially decreases entrainment, decreases convective intensity, and increases LWP for most models. In nearly all cases, LWP responds more strongly to cloud water sedimentation than to drizzle. The omission of cloud water sedimentation in simulations is strongly discouraged, regardless of whether or not precipitation is present below cloud base.

The role of boundary-layer convergence zones and horizontal rolls in the initiation of thunderstorms : a case study

Abstract The initiation of thunderstorms is examined through a combined observational and modeling case study. The study is based on Doppler radar, aircraft, mesonet, balloon sounding, and profiler and photographic data from the Convection Initiation and Downburst Experiment (CINDE) conducted near Denver, Colorado. The study examines the initiation of a line of thunderstorms that developed along a preexisting, quasi-stationary boundary-layer convergence line on 17 July 1987. The storms were triggered at the intersection of the convergence line with horizontal rolls where enhanced updrafts were present. The primary effect of the convergence line was to deepen the moist layer locally and provide a region potentially favorable to deep convection. The critical factor governing the time of storm development was apparently related to the attainment of a balance between horizontal vorticity in the opposing flows on either side of the convergence line. The effect was to cause the updrafts in the convergence line ...

Intercomparison and evaluation of cumulus parametrizations under summertime midlatitude continental conditions

This study reports the Single-Column Model (SCM) part of the Atmospheric Radiation Measurement (ARM)/the Global Energy and Water Cycle Experiment (GEWEX) Cloud System Study (GCSS) joint SCM and Cloud-Resolving Model (CRM) Case 3 intercomparison study, with a focus on evaluation of cumulus parametrizations used in SCMs. Fifteen SCMs are evaluated under summertime midlatitude continental conditions using data collected at the ARM Southern Great Plains site during the summer 1997 Intensive Observing Period. Results from ten CRMs are also used to diagnose problems in the SCMs. It is shown that most SCMs can generally capture well the convective events that were well-developed within the SCM domain, while most of them have difficulties in simulating the occurrence of those convective events that only occurred within a small part of the domain. All models significantly underestimate the surface stratiform precipitation. A third of them produce large errors in surface precipitation and thermodynamic structures. Deficiencies in convective triggering mechanisms are thought to be one of the major reasons. Using a triggering mechanism that is based on the vertical integral of parcel buoyant energy without additional appropriate constraints results in overactive convection, which in turn leads to large systematic warm/dry biases in the troposphere. It is also shown that a non-penetrative convection scheme can underestimate the depth of instability for midlatitude convection, which leads to large systematic cold/moist biases in the troposphere. SCMs agree well quantitatively with CRMs in the updraught mass fluxes, while most models significantly underestimate the downdraught mass fluxes. Neglect of mesoscale updraught and downdraught mass fluxes in the SCMs contributes considerably to the discrepancies between the SCMs and the CRMs. In addition, uncertainties in the diagnosed mass fluxes in the CRMs and deficiencies with cumulus parametrizations are not negligible. Similar results are obtained in the sensitivity tests when different forcing approaches are used. Finally, sensitivity tests from an SCM indicate that its simulations can be greatly improved when its triggering mechanism and closure assumption are improved.

A comparison of single column model simulations of summertime midlatitude continental convection

Eleven different single-column models (SCMs) and one cloud ensemble model (CEM) are driven by boundary conditions observed at the Atmospheric Radiation Measurement (ARM) program southern Great Plains site for a 17 day period during the summer of 1995. Comparison of the model simulations reveals common signatures identifiable as products of errors in the boundary conditions. Intermodel differences in the simulated temperature, humidity, cloud, precipitation, and radiative fluxes reflect differences in model resolution or physical parameterizations, although sensitive dependence on initial conditions can also contribute to intermodel differences. All models perform well at times but poorly at others. Although none of the SCM simulations stands out as superior to the others, the simulation by the CEM is in several respects in better agreement with the observations than the simulations by the SCMs. Nudging of the simulated temperature and humidity toward observations generally improves the simulated cloud and radiation fields as well as the simulated temperature and humidity but degrades the precipitation simulation for models with large temperature and humidity biases without nudging. Although some of the intermodel differences have not been explained, others have been identified as model problems that can be or have been corrected as a result of the comparison.

GEWEX Cloud System Study (GCSS) Working Group 4: Precipitating Convective Cloud Systems

Abstract The authors present the objectives of the working group on precipitating convective cloud systems. These center on developing physically based parameterizations for global models in which basic research into the large-scale role of cloud systems is an important part. The approach calls on a range of expertise: cloud-resolving modeling and contributing research, observational evaluation of the model results, and tests of parameterizations in single-column models. Ongoing studies focus on oceanic cloud systems in Tropical Oceans Global Atmosphere Coupled Ocean–Atmosphere Research Experiment (TOGA COARE). First, cloud-resolving modeling of organized convection on a timescale of a few hours concentrates on momentum transport and surface fluxes. Results are evaluated against data obtained during the 22 February 1993 Intensive Observation Period, which include airborne Doppler radar measurements of a squall line. Second, multiday simulations focus on the environmental effects of cloud systems as they r...