Grace periods and exposure misclassification in self-controlled case-series studies of drug-drug interactions.

The self-controlled case-series (SCCS) research design is increasingly used in pharmacoepidemiologic studies of drug-drug interactions (DDIs), with the target of inference being the incidence rate ratio (IRR) associated with concomitant exposure to the object plus precipitant drug versus the object drug alone. While day-level drug exposure can be inferred from dispensing claims, these inferences may be inaccurate, leading to biased IRRs. Grace periods (periods assuming continued treatment impact after days' supply exhaustion) are frequently used by researchers, but the impact of grace period decisions on bias from exposure misclassification remains unclear. Motivated by an SCCS study examining the potential DDI between clopidogrel (object) and warfarin (precipitant), we investigated bias due to precipitant or object exposure misclassification using simulations. We show that misclassified precipitant treatment always biases the estimated IRR toward the null, whereas misclassified object treatment may lead to bias in either direction or no bias, depending on the scenario. Further, including a grace period for each object dispensing may unintentionally increase the risk of misclassification bias. To minimize such bias, we recommend 1) avoiding the use of grace periods when specifying object drug exposure episodes; and 2) including a washout period following each precipitant exposed period.

Prediction of Major Adverse Cardiac Events After Transcatheter Aortic Valve Implantation: A Machine Learning Approach with GRACE Score.

Objectives: Predictive risk scores have a significant impact on patient selection and assessing the likelihood of complications following interventions in patients with severe aortic stenosis (AS). This study aims to explore the utility of machine learning (ML) techniques in predicting 30-day major adverse cardiac events (MACE) by analyzing parameters, including the Global Registry of Acute Coronary Events (GRACE) score. Methods: This retrospective, multi-center, observational study enrolled 453 consecutive patients diagnosed with severe AS who underwent transcatheter aortic valve implantation (TAVI) from April 2020 to January 2023. The primary outcome was defined as a composition of MACE comprising periprocedural myocardial infarction (MI), cerebrovascular events (CVE), and all-cause mortality during the 1-month follow-up period after the procedure. Conventional binomial logistic regression and ML models were utilized and compared for prediction purposes. Results: The study population had a mean age of 76.1, with 40.8% being male. The primary endpoint was observed in 7.5% of cases. Among the individual components of the primary endpoint, the rates of all-cause mortality, MI, and CVE were reported as 4.2%, 2.4%, and 1.9%, respectively. The ML-based Extreme Gradient Boosting (XGBoost) model with the GRACE score demonstrated superior discriminative performance in predicting the primary endpoint, compared to both the ML model without the GRACE score and the conventional regression model [Area Under the Curve (AUC)= 0.98 (0.91-0.99), AUC= 0,87 (0.80-0.98), AUC= 0.84 (0.79-0.96)]. Conclusion: ML techniques hold the potential to enhance outcomes in clinical practice, especially when utilized alongside established clinical tools such as the GRACE score.

Watching the Grand Ethiopian Renaissance Dam from a distance: Implications for sustainable water management of the Nile water.

Increased demands for sustainable water and energy resources in densely populated basins have led to the construction of dams, which impound waters in artificial reservoirs. In many cases, scarce field data led to the development of models that underestimated the seepage losses from reservoirs and ignored the role of extensive fault networks as preferred pathways for groundwater flow. We adopt an integrated approach (remote sensing, hydrologic modeling, and field observations) to assess the magnitude and nature of seepage from such systems using the Grand Ethiopian Renaissance Dam (GERD), Africa's largest hydropower project, as a test site. The dam was constructed on the Blue Nile within steep, highly fractured, and weathered terrain in the western Ethiopian Highlands. The GERD Gravity Recovery and Climate Experiment Terrestrial Water Storage (GRACETWS), seasonal peak difference product, reveals significant mass accumulation (43 ± 5 BCM) in the reservoir and seepage in its surroundings with progressive south-southwest mass migration along mapped structures between 2019 and 2022. Seepage, but not a decrease in inflow or increase in outflow, could explain, at least in part, the observed drop in the reservoir's water level and volume following each of the three fillings. Using mass balance calculations and GRACETWS observations, we estimate significant seepage (19.8 ± 6 BCM) comparable to the reservoir's impounded waters (19.9 ± 1.2 BCM). Investigating and addressing the seepage from the GERD will ensure sustainable development and promote regional cooperation; overlooking the seepage would compromise hydrological modeling efforts on the Nile Basin and misinform ongoing negotiations on the Nile water management.

Short- and long-term performance of risk calculation tools for mortality in patients with acute coronary syndrome.

Background: The mortality rate of acute coronary syndrome (ACS) remains high. Therefore, patients with ACS should undergo early risk stratification, for which various risk calculation tools are available. However, it remains uncertain whether the predictive performance varies over time between risk calculation tools for different target periods. This study aimed to compare the predictive performance of risk calculation tools in estimating short- and long-term mortality risks in patients with ACS, while considering different observation periods using time-dependent receiver operating characteristic (ROC) analysis. Methods: This study included 404 consecutive patients with ACS who underwent coronary angiography at our hospital from March 2017 to January 2021. The ACTION and GRACE scores for short-term risk stratification purposes and CRUSADE scores for long-term risk stratification purposes were calculated for all participants. The participants were followed up for 36 months to assess mortality. Using time-dependent ROC analysis, we evaluated the area under the curve (AUC) of the ACTION, CRUSADE, and GRACE scores at 1, 6, 12, 24, and 36 months. Results: Sixty-six patients died during the observation periods. The AUCs at 1, 6, 12, 24, and 36 months of the ACTION score were 0.942, 0.925, 0.889, 0.856, and 0.832; those of the CRUSADE score were 0.881, 0.883, 0.862, 0.876, and 0.862; and those of the GRACE score 0.949, 0.928, 0.888, 0.875, and 0.860, respectively. Conclusions: The ACTION and GRACE scores were excellent risk stratification tools for mortality in the short term. The prognostic performance of each risk score was almost similar in the long term, but the CRUSADE score might be a superior risk stratification tool in the longer term than 3 years.

Comparison of groundwater storage changes over losing and gaining aquifers of China using GRACE satellites, modeling and in-situ observations.

Groundwater depletion in intensively exploited aquifers of China has been widely recognized, whereas an overall examination of groundwater storage (GWS) changes over major aquifers remains challenging due to limited data and notable uncertainties. Here, we present a study to explore GWS changes over eighteen major aquifers covering an area of 1,680,000 km2 in China using data obtained from the Gravity Recovery and Climate Experiments (GRACE), global models, and in-situ groundwater level observations. The analysis aims to reveal the discrepancy in annual trends, amplitudes, and phases associated with GWS changes among different aquifers. It is found that GWS changes in the studied aquifers represent a spatial pattern of 'Wet-gets-more, Dry-gets-less'. An overall decreasing trend of -4.65 ± 0.34 km3/yr is observed by GRACE from 2005 to 2016, consisting of a significant (p < 0.05) increase of 47.28 ± 3.48 km3 in 7 aquifers and decrease of 103.56 ± 2.4 km3 (∼2.6 times the full storage capacity of the Three Gorges Reservoir) in 10 aquifers summed over the 12 years. The annual GWS normally reaches a peak in late July with an area-weighted average annual amplitude of 19 mm, showing notable discrepancy in phases and amplitudes between the losing aquifers (12 mm in middle August) in northern China and gaining aquifers (28 mm in early July) mostly in southern China. GRACE estimates are generally comparable, but can be notably different, with the results obtained from model simulations and in-situ observations at aquifer scale, with the area-weighted average correlation coefficients of 0.6 and 0.5, respectively. This study highlights different GWS changes of losing and gaining aquifers in response to coupled impacts of hydrogeology, climate and human interventions, and calls for divergent adaptions in regional groundwater management.

The Predictive Value of Geriatric Nutritional Risk Index Combined with the GRACE Score in Predicting the Risk of One Year Poor Prognosis in Elderly Patients with Non-ST Segment Elevation Myocardial Infarction After PCI.

Background: As a nutritional indicator, a lower level of geriatric nutritional risk index (GNRI) has been suggested as a predictor for poor prognosis in acute coronary syndrome (ACS). However, whether GNRI could improve the predictive value of the Global Registry of Acute Coronary Events (GRACE) score for the prognosis in elderly patients with non-ST segment elevation myocardial infarction (NSTEMI) after PCI remains unclear. Methods: A total of 446 elderly patients with NSTEMI after percutaneous coronary intervention (PCI) were consecutively enrolled. Patients were divided into major adverse cardiovascular and cerebrovascular events (MACCE) group and control group according to the occurrence of MACCE during one year follow up. The clinical parameters including GNRI were compared to investigate the predictors for MACCE. The performance after the addition of GNRI to the GRACE score for predicting MACCE was determined. Results: A total of 68 patients developed MACCE. In unadjusted analyses, the rate of MACCE was significantly higher in the 93.8

The association between GRACE score at admission for myocardial infarction and the incidence of sudden cardiac arrests in long-term follow-up - the MADDEC study.

Background. Sudden cardiac arrest (SCA), often also leading to sudden cardiac death (SCD), is a common complication in coronary artery disease. Despite the effort there is a lack of applicable prediction tools to identify those at high risk. We tested the association between the validated GRACE score and the incidence of SCA after myocardial infarction. Material and methods. A retrospective analysis of 1,985 patients treated for myocardial infarction (MI) between January 1st 2015 and December 31st 2018 and followed until the 31st of December of 2021. The main exposure variable was patients' GRACE score at the point of admission and main outcome variable was incident SCA after hospitalization. Their association was analyzed by subdistribution hazard (SDH) model analysis. The secondary endpoints included SCA in patients with no indication to implantable cardioverter-defibrillator (ICD) device and incident SCD. Results. A total of 1985 patients were treated for MI. Mean GRACE score at baseline was 118.7 (SD 32.0). During a median follow-up time of 5.3 years (IQR 3.8-6.1 years) 78 SCA events and 52 SCDs occurred. In unadjusted analyses one SD increase in GRACE score associated with over 50% higher risk of SCA (SDH 1.55, 95% CI 1.29-1.85, p < 0.0001) and over 40% higher risk for SCD (1.42, 1.12-1.79, p = 0.0033). The associations between SCA and GRACE remained statistically significant even with patients without indication for ICD device (1.57, 1.30-1.90, p < 0.0001) as well as when adjusting with patients LVEF and omitting the age from the GRACE score to better represent the severity of the cardiac event. The association of GRACE and SCD turned statistically insignificant when adjusting with LVEF. Conclusions. GRACE score measured at admission for MI associates with long-term risk for SCA.

What is already known about this subject?Nearly 50% of cardiac mortality is caused by sudden cardiac death, often due to sudden cardiac arrest.Despite the effort, there is a lack of applicable prediction tools to identify those at high risk.What does this study add?This study shows that GRACE score measured at the point of admission for myocardial infarction can be used to evaluate patients' risk for sudden cardiac arrest in a long-term follow-up.How might this impact on clinical practice?Based on our findings, the GRACE score at the point of admission could significantly affect the patients' need for an ICD device after hospitalization for MI and should be considered as a contributing factor when evaluating the patients' follow-up care.

Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis.

ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.

The analysis on groundwater storage variations from GRACE/GRACE-FO in recent 20 years driven by influencing factors and prediction in Shandong Province, China.

Monitoring and predicting the regional groundwater storage (GWS) fluctuation is an essential support for effectively managing water resources. Therefore, taking Shandong Province as an example, the data from Gravity Recovery and Climate Experiment (GRACE) and GRACE Follow-On (GRACE-FO) is used to invert GWS fluctuation from January 2003 to December 2022 together with Watergap Global Hydrological Model (WGHM), in-situ groundwater volume and level data. The spatio-temporal characteristics are decomposed using Independent Components Analysis (ICA), and the impact factors, such as precipitation and human activities, which are also analyzed. To predict the short-time changes of GWS, the Support Vector Machines (SVM) is adopted together with three commonly used methods Long Short-Term Memory (LSTM), Singular Spectrum Analysis (SSA), Auto-Regressive Moving Average Model (ARMA), as the comparison. The results show that: (1) The loss intensity of western GWS is significantly greater than those in coastal areas. From 2003 to 2006, GWS increased sharply; during 2007 to 2014, there exists a loss rate - 5.80 ± 2.28 mm/a of GWS; the linear trend of GWS change is - 5.39 ± 3.65 mm/a from 2015 to 2022, may be mainly due to the effect of South-to-North Water Diversion Project. The correlation coefficient between GRACE and WGHM is 0.67, which is consistent with in-situ groundwater volume and level. (2) The GWS has higher positive correlation with monthly Global Precipitation Climatology Project (GPCP) considering time delay after moving average, which has the similar energy spectrum depending on Continuous Wavelet Transform (CWT) method. In addition, the influencing facotrs on annual GWS fluctuation are analyzed, the correlation coefficient between GWS and in-situ data including the consumption of groundwater mining, farmland irrigation is 0.80, 0.71, respectively. (3) For the GWS prediction, SVM method is adopted to analyze, three training samples with 180, 204 and 228 months are established with the goodness-of-fit all higher than 0.97. The correlation coefficients are 0.56, 0.75, 0.68; RMSE is 5.26, 4.42, 5.65 mm; NSE is 0.28, 0.43, 0.36, respectively. The performance of SVM model is better than the other methods for the short-term prediction.

A State of Grace: Community, Self-Consciousness, and Faith in W.H. Auden's "The Age of Anxiety".

In this essay, the author examines a highly influential poem, The Age of Anxiety by W.H. Auden, for its engagement with anxiety and religious faith in the modern world. Published in 1947, the book-length poem reveals Auden's deep understanding of western psychology, Judaism, and Christianity. The author argues for the relevance of The Age of Anxiety in this modern moment, but demonstrates that this relevance does not derive from any direct diagnostic or therapeutic implications of the poem. Rather, Auden's work provides readers with an image of a state of grace in the middle of an age of anxiety.

Evaluating flood potential in the Mahanadi River Basin, India, using Gravity Recovery and Climate Experiment (GRACE) data and topographic flood susceptibility index under non-stationary framework.

Extreme flood events have been recorded recently in the Mahanadi River basin in India with a high destructive potential that causes large social and economic damages. Because fewer hydrometeorological stations can record the flood magnitude in the basin, exploring new datasets like Gravity Recovery and Climate Experiment (GRACE) becomes important to overcome the barriers of assessing the hydrological extremes. The study estimates the flood potential using the GRACE-based terrestrial water storage (TWS) and analytical hierarchy process (AHP)-based topographic flood susceptibility to model the non-stationary flood frequency. During extreme flood events, the magnitude of the combined flood potential index (CFPI) is high (CFPI > 0.6), which correlates with higher river discharge. The CFPI value for the 2012 flood event with a discharge of 11,000 m3/sec (corresponds to a 35-year return period) is recorded at 0.67. Likewise, the CFPI for the flood event in 2011, which corresponds to a return period of 17 years, also stands at 0.63. The overall correlation between the discharge values of various flood events and CFPI values is above 0.8 for all locations, indicating GRACE-based CFPI's applicability for identifying the flood risk for larger basins like Mahanadi. Furthermore, on integrating CFPI as a covariate in non-stationary flood frequency modeling, the study found its superior performance when compared to both stationary models and non-stationary models with time or other climate indices as covariates, thus, helping in accurate estimation of flood return levels that are very useful in the hydrological design of water resources projects.

Evaluating groundwater resources trends through multiple conceptual models and GRACE satellite data.

In this research, three numerical groundwater flow models, developed and calibrated from three equally plausible conceptual models over the Nasia Basin, have been used to assess groundwater resources variations over a transient period. The use of multiple numerical models reduces the effect of uncertainties in conceptual model formulation. All the three calibrated numerical models indicate an increasing trend of groundwater recharge and storage over the period of the groundwater level monitoring. This suggests that the prevailing erratic climatic conditions in the area are conducive for increasing groundwater recharge and storage in the terrain. The high-intensity, short duration rainfall patterns, attending climate change in the basin, enhance high levels of infiltration and percolation, leading to steadily increasing groundwater recharge. Groundwater recharge estimates from each of the models over the transient period appear to reflect the pattern of seasonal variations in rainfall in the region. Data from the models indicates a significant role of baseflow in sustaining perennial streamflow in the area. This presents a significant development in terms of groundwater-based adaptation projects, especially in agriculture. The trend of groundwater recharge in the Nasia Basin is in sync with regional groundwater storage variations estimated from the Gravity Recovery and Climate Experiment (GRACE) satellite data collected and processed over the Volta Basin. At the Volta Basin level, groundwater storage variations indicate a strong positive trend of increasing groundwater recharge from 2002 (beginning of the GRACE mission) to 2022 (end point of the data used for this research). Analysis of the GRACE data suggests that there is a cumulative increase in groundwater storage by 30 cm, representing approximately 120 km3 of groundwater over the period in the basin. This translates into approximately 15 mm/year of groundwater storage increase. Thus, at both the regional and local levels, groundwater appears to be responding positively to the impacts of erratic rainfall patterns observed in the area recently. The high-intensity, short duration rainfall patterns appear to favor significant groundwater recharge, resulting in a strong positive groundwater storage signal. The high positive groundwater storage signal suggests increasing groundwater resources potential in the area, indicating promising opportunities for groundwater-based climate change adaptation interventions.

Long-term spatiotemporal dynamics of groundwater storage in the data-scarce region: Tana sub-basin, Ethiopia.

Imprudent extraction of groundwater tends to undue stress and portends its sustainability. Spatiotemporal analysis of groundwater storage anomaly (GWSA) is imperative for the judicious use, management, and sustainable development of a region. This study aimed to examine the changes in groundwater storage over the past 20 years in the Tana sub-basin using Gravity Recovery and Climate Experiment (GRACE) assimilated into Global Land Data Assimilation Systems (GLDAS). Validation analysis was carried out to evaluate the accuracy of GWSA against anomalies of Lake Tana water level, precipitation, and in-situ groundwater level. Modified Mann-Kendal test and Sen's slope estimator were applied for trend analysis of the GWSA. The results exhibited that GWSA strongly correlated (Pearson's correlation coefficient, R ranges from 0.75 to 0.96) with the three validation above variables, which elucidated in general, credible GWSA estimation. The net annual GWSA curve showed a non-significant (p > 0.05) decreasing trend from 2003 to 2012. However, years including 2005, 2006, and 2009 were drought periods, which caused 0.49 billion cubic meters (BCM) groundwater loss. In the entire study period (2003-2022), on the other hand, the net annual GWSA revealed a significant increasing trend (p < 0.05) with a rate of 0.333 cm/year. Generally, the Tana sub-basin was nurtured with a net 4.87 BCM groundwater gain in the study period. The most sensitive parts of the study area to large fluctuations of groundwater storage were mainly the nearby southern and eastern directions of Lake Tana.

The possible utility of global longitudinal strain in the risk-stratifying process of non-ST elevation-acute coronary syndrome.

BACKGROUND: There are various ways that coronary artery disease (CAD) might present itself. Individual risk stratification for non ST-elevation-acute coronary syndrome (NSTE-ACS) patients should determine whether invasive coronary angiography and revascularization should be scheduled. AIM OF WORK: To assess the possible utility of left ventricular global longitudinal strain in the risk-stratifying process of NSTE-ACS. SUBJECTS AND METHODS: The cardiology department of Zagazig University in Egypt organized and oversaw this cross-sectional study. The practical portion was carried out on 90 patients with NSTE-ACS based on European society of cardiology (ESC) guidelines (and they agreed for invasive strategy) between May 2019 and December 2020 at Salalah Heart Center in Sultanate of Oman. All patients underwent a full clinical examination, 12-lead ECG, and serial high-sensitivity troponin T (hs-TnT) in addition to a thorough history taking process. On patient's admission, the GRACE risk score was assessed. All patients who were suspected of having NSTE-ACS upon admission underwent transthoracic echocardiography, including two-dimensional speckle tracking (2D-ST). Left ventricular global longitudinal strain (LV-GLS %) was measured and analyzed using 2D speckle tracking. SYNTAX Score was determined for all patients. RESULTS: By analysis of the performance of LV-GLS% in prediction of high risk by GRACE score, we found that with cutoff (≥-13.8), the AUC was (0.944) with sensitivity, specificity, PPV, NPV, and accuracy (0.944, 93.3%, 84%, 53.8%, 98.4%, 85.6%), respectively. CONCLUSION: Global longitudinal strain can predict accurately high-risk NSTE-ACS patients by GRACE score.

To Evaluate Platelet Indices, Platelet to Lymphocyte Ratio and Neutrophil to Lymphocyte Ratio as Prognostic and Risk Factors in Patients with Coronary Artery Disease.

To evaluate platelet indices, platelet to lymphocyte ratio and neutrophil to lymphocyte ratio as prognostic and risk factors in patients with coronary artery disease Introduction: cardiovascular diseases have 12 million deaths annually which is one of the commonest causes of death globally. Platelet parameters like Mean platelet volume (MPV), platelet distribution width (PDW) and WBC parameters like Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio(PLR) have recently been emerging as a new prognostic marker in number of coronary artery disease (CAD) with limited studies to explore their utility. AIMS AND OBJECTIVES: this study aimed to evaluate MPV, P-LCR, PDW, PLR, NLR and GRACE risk score in CAD patients. MATERIAL AND METHODS: this descriptive cross-sectional study was done in 330 cases of CAD and 200 healthy controls were studied.MPV, platelet-large cell ratio (P-LCR), PLR, NLR and PDW of patients were analyzed. RESULTS: In our study, 245 were males and 85 were females. Mean PDW, MPV, Mean PLCR, Mean NLR was significantly higher in CAD cases as compared to controls (p value < 0.05). Mean PLR was not significantly different in CAD cases and controls. MPV was more associated risk predictor of CAD (8.98 times) followed by NLR (2.79 times), PDW (1.53 times) and PLCR (1.02 times). DISCUSSION AND CONCLUSION: platelet indices, NLR and PLR are simple cost effective parameters and in future these might be useful adjuvant tests in conjunction with conventional biochemical cardiac markers in early prediction of risk of CAD in patients admitted to hospital and can guide clinicians in assessing the prognosis on short and long term follow up of these patients in terms of morbidity and mortality.

Analyzing post-2000 groundwater level and rainfall changes in Rajasthan, India, using well observations and GRACE data.

Research on groundwater and water resources is essential for preserving viable environments. Although the arid area has been identified as a significant hotspot for groundwater depletion, the Indian desert region was not included in the initial analysis. This study intends to evaluate Rajasthan's groundwater level (GWL) and rainfall trends from 2000 to 2021 and how variations in GWLs are related to long-term rainfall. Annual GWL and rainfall data time series were collected from 921 monitoring stations for 33 districts of Rajasthan. The GWL trends and rainfall were identified using non-parametric modified Mann-Kendall test and Spearman rho techniques. Pearson's, Kendall's (tau b), and Spearman's analyses were used to determine the correlation between GWL and rainfall. The results from the modified Mann-Kendall and Spearman rho methods reveal that GWL has a significant declining trend in 38 % of districts, where 13 % have no trend, and the rest of 49 % have a rising trend. The yearly rainfall trend at 70 % and 30 % of the districts are rising and stable, respectively. A negative correlation between GWL depth and rainfall was discovered in each district, where 15 % are firm, 58 % are moderate, and 27 % are weak negative correlations. Also, the regression analysis estimates the effect of rainfall on GWL, which was observed: rainfall negatively influenced the depth of GWL at 58 % of the districts, had a positive impact at 33 %, and others had no effect. GRACE TWS anomaly shows a decreasing trend of -1.22 cm/yr, and GRACE and GWL anomalies have a positive relationship (r = 0.471). Results conclude that rainfall is the primary influencer on GWL in this semi-arid region vulnerable to drought.

Can GRACE Risk Score Predict Mortality and the Need for Thrombolytic Treatment in Acute Pulmonary Embolism?

Acute coronary syndrome and pulmonary embolism (PE) are clinical entities sharing similar presentation and risk factors. Risk scores and indexes help to identify disease severity in both diseases. In this study, we aimed to evaluate if the Global Registry of Acute Coronary Events (GRACE) risk score could predict 30-day mortality and the need for thrombolytic treatment in patients with acute PE. Patients hospitalized with a diagnosis of PE in our tertiary center between January 2018 and May 2022 were included in this retrospective study. Pulmonary Embolism Severity Index (PESI) and GRACE risk scores on admission were calculated using clinical, electrocardiographic, and laboratory parameters for each patient. A total of 197 patients were included. The 30-day mortality rate was 28.4% whereas 32.5% of the patients required thrombolytic treatment. GRACE and PESI scores were found independent risk factors associated with 30-day mortality and the need for thrombolytic treatment. A cut-off value of 160.5 for GRACE score was associated with 88.5% sensitivity and 89.4% specificity in prediction of 30-day mortality. In contrast, GRACE score had 61.0% sensitivity and 60.0% specificity in the prediction of the need for thrombolytic treatment when the cut-off value was 147. In conclusion, GRACE risk score has an effective discriminating power in determining the early mortality of patients with acute PE. The incidence of short-term PE-related mortality was significantly increased in patients with high GRACE risk scores. Concomitant use of GRACE and PESI risk scores may aid in defining patients with high-risk PE and help predict poor prognosis with high specificity and probability.

GRACE scores or high-sensitivity troponin for timing of coronary angiography in non-ST-elevation acute coronary syndromes.

BACKGROUND: The GRACE risk score is generically recommended by guidelines for timing of invasive coronary angiography without stating which score should be used. The aim was to determine the diagnostic performance of different GRACE risk scores in comparison to the ESC 0/1 h-algorithm using high-sensitivity cardiac troponin (hs-cTn). METHODS: Prospectively enrolled patients presenting with symptoms suggestive of myocardial infarction (MI) in two large studies testing biomarker diagnostic strategies were included. Five GRACE risk scores were calculated. The amount of risk reclassification and the theoretical impact on guideline-recommended timing of invasive coronary angiography was studied. RESULTS: Overall, 8,618 patients were eligible for analyses. Comparing different GRACE risk scores, up to 63.8% of participants were reclassified into a different risk category. The proportion of MIs identified (i.e., sensitivity) dramatically differed between GRACE risk scores (range 23.8-66.5%) and was lower for any score than for the ESC 0/1 h-algorithm (78.1%). Supplementing the ESC 0/1 h-algorithm with a GRACE risk score slightly increased sensitivity (P < 0.001 for all scores). However, this increased the number of false positive results. CONCLUSION: The substantial amount of risk reclassification causes clinically meaningful differences in the proportion of patients meeting the recommended threshold for pursuing early invasive strategy according to the different GRACE scores. The single best test to detect MIs is the ESC 0/1 h-algorithm. Combining GRACE risk scoring with hs-cTn testing slightly increases the detection of MIs but also increases the number of patients with false positive results who would undergo potential unnecessarily early invasive coronary angiography.

Alternative approaches to measuring value: an update on innovative methods in the context of the United States Medicare drug price negotiation program.

INTRODUCTION: The United States has begun assessing the value of pharmaceuticals to inform negotiated prices in the Medicare program. Given strong political objections in the United States to the use of QALYs, Medicare will need to adopt an alternative approach to measuring value. AREAS COVERED: In this narrative review, we identified six alternative approaches to measuring value (equal value life-years, health years in total, generalized risk-adjusted cost-effectiveness, severity weighting based on absolute or proportional shortfall, comparative effectiveness based on conventional clinical endpoints, and comparative effectiveness based on both conventional endpoints and patient-centric value elements) and five criteria for assessing these approaches (responsiveness to concerns about discrimination, feasibility, transparency, flexibility, and the ability to incorporate factors beyond traditional value elements). EXPERT OPINION: Four of the alternatives are broadly aligned with the cost-effectiveness framework, but none fully addresses all aspects of the stated concerns that QALYs may be used to unintentionally implement discrimination. We note, however, that the extent to which these concerns lead to discrimination in practice is unknown. Finally, we recommend an approach for measuring value in terms of comparative effectiveness that combines quantitative ranking and weighting of distinct criteria (including patient-centric value elements) with deliberation.

Association between anaemia and long-term prognosis in patients with non-ST segment elevation myocardial infarction.

BACKGROUND: The majority of existing studies examining the association between anaemia and the prognosis of patients with acute coronary syndrome (ACS) have focused on all patients with ACS without further categorisation. As a result, there is a dearth of research specifically exploring the relationship between anaemia and the long-term prognosis of patients with non-ST segment elevation myocardial infarction (NSTEMI). To address this gap, this study aimed to investigate the correlation between anaemia and the long-term prognosis of NSTEMI patients. METHODS: This study included 482 NSTEMI patients who underwent percutaneous coronary intervention (PCI) at the First Affiliated Hospital of Chongqing Medical University from September 1, 2016 to May 31, 2022, and the patients were classified into the major adverse cardiovascular events (MACE) group and non-MACEs group according to whether or not they had developed MACE as of February 28, 2023 at follow-up.COX regression analysis was used to assess whether anaemia was an independent factor influencing MACE occurrence in patients with NSTEMI. Receiver operating characteristic (ROC) curve analysis was conducted to determine if haemoglobin levels could enhance the predictive capacity of the Global Registry of Acute Coronary Events (GRACE) score for the prognosis of NSTEMI patients. Haemoglobin levels were categorised into two groups based on the optimal cut-off value and transformed into binary data. The log-rank test was performed to compare the two groups, and a risk function was plotted. RESULTS: During a median follow-up period of 31 months, 124 (25.7%) MACE were identified. Univariate and multivariate COX regression analyses revealed that sex, age, smoking history, diabetes, creatinine, erythrocyte count, and haemoglobin level were independent risk factors that significantly influenced survival time. Subsequently, ROC curve analysis was performed to evaluate the predictive accuracy of specific variables. When the cut-off value for the decline ratio of haemoglobin was set at 128.50, the area under the curve (AUC) was determined to be 0.604, with a sensitivity of 0.403 and a specificity of 0.771. Similarly, setting the cut-off value for the reduction ratio of the GRACE score at 141.5 yielded an AUC of 0.700, with a sensitivity of 0.645 and a specificity of 0.709. Furthermore, when the cut-off value for the predicted probability of haemoglobin combined with the GRACE score was 0.270, the AUC was calculated as 0.702, with a sensitivity of 0.677 and a specificity of 0.696. CONCLUSION: Haemoglobin levels were identified as an independent factor influencing the survival duration of patients with NSTEMI.