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We thank Dr. Madias and Dr. El-Battrawy et al. for their thoughtful comments on our recently published study [(1)][1], which showed that donor hearts with left ventricular systolic dysfunction (LVSD) that are successfully resuscitated can be transplanted without increasing recipient mortality

Introduction Acute decompensated heart failure (ADHF) readmission rates are high and act as a burden to both the patient and the healthcare system. Non-invasive measures of hemodynamic status are limited in accuracy, leading to patients being discharged with residual congestion and a higher likelihood of subsequent readmission for ADHF. Peripheral venous pressure (PVP) measurement involves transducing a peripheral intravenous (PIV) catheter and may serve as a minimally invasive method of determining hemodynamic status in patients with ADHF. PVP measurements have been shown to correlate with CVP measurements in heart failure patients, but the clinical relevance of this has not yet been established. We sought to examine if PVP measurements may predict heart failure readmission. Methods A prospective feasibility study was conducted from July to December 2018. Patients admitted with ADHF were enrolled on day-of-discharge. Using a standard pressure transducer leveled to the phlebostatic access, measurement of PVP was performed at the bedside using a previously-inserted PIV. The electronic medical record was reviewed for subsequent readmissions. The primary end-point was readmission at 30 days post-discharge. Results 29 patients were enrolled. The mean age of participants was 65.6 +/- 10.8 years. 66% of patients were male and 55% of patients were black. 72% of patients had a reduced ejection fraction (EF) and 28% had a preserved EF. At the time of discharge, the mean PVP was 11.6 +/- 4.9 mmHg. 5 patients (17%) were readmitted within 30 days. Mean PVP for those readmitted was 12.0 +/- 2.1 mmHg vs 11.5 +/- 5.3 mmHg for those without readmission (difference of the means 0.5 mmHg, p= 0.86). PVP was not significantly impacted by whether a 22-gauge or 20-gauge PIV was used (difference of means 2.3 mmHg, p= 0.51). Waveform analysis on a subset of patients showed lower PVP in those with a sinusoidal waveform as opposed to a flatline or static waveform (12.8 vs. 17.4 mmHg, p=0.32). Conclusion In this small feasibility study, few patients were readmitted for heart failure in 30 days. PVP was similar among the 5 patients readmitted with ADHF. PVP measurement was readily obtainable and PVP was not significantly impacted by PIV gauge. Further study of this clinical application to PVP measurement is warranted.

Introduction The vasoactive inotropic score (VIS) is an emerging method to estimate total inotropic and vasopressor support after cardiothoracic surgery. Whether the post-operative VIS score can predict mortality in patients following LVAD implantation is unknown. Methods We performed a single-center retrospective study of 268 patients who received a continuous-flow durable LVAD between Jan 1, 2006 and Dec 31, 2017. The VIS score was calculated as: dobutamine (mcg/kg/min) + 10 x milrinone (mcg/kg/min) + dopamine (mcg/kg/min) + 100 x epinephrine (mcg/kg/min) + 100 x norepinephrine (mcg/kg/min) + 10,000 x vasopressin (units/kg/min). The VIS score at 6, 24, and 48 hours postoperatively were abstracted and then the maximum VIS score within 48 hours after implantation for each patient was used to stratify the cohort into quartiles. Kaplan-Meier method was used to estimate 90-day survival and Cox Hazard model was performed to evaluate for predictors of 90-day mortality. Results The VIS quartiles groups were 0-9, 10-16, 17-23, and 24-87. Patients in quartile 4 were older and had a higher preoperative right atrial pressure (Table 1). VIS quartiles demonstrate a stepwise increase in adjusted hazard ratio compared to the 1st quartile in our multivariable model (which included age, total bilirubin over 2.5, gender, and VIS) with VIS quartile 2 HR 2.45 (95% CI 0.65 - 9.24, p = 0.18), VIS quartile 3 HR 3.39 (95% CI 0.90 - 12.79, p = 0.07), VIS quartile 4 HR 4.53 (95% CI 1.28 - 16.05, p = 0.02). Figure 1 demonstrates worsened survival by VIS quartiles up to 90-days post LVAD implantation (logrank test p=0.048). Conclusion Elevated VIS score within the first 48 hours after LVAD implantation correlates with an increased risk of mortality at 90 days. Further work is needed to confirm this relationship.

Purpose Gastrointestinal bleeding (GIB) in patients supported by Continuous-Flow Left Ventricular Assist Devices (CF-LVAD) is most commonly caused by gastrointestinal angiodysplasia (GIAD). It has been postulated that the abnormal hemodynamic profile in CF-LVAD patients can cause splanchnic submucosal hypoperfusion and activate a Hypoxia Inducible Factor (HIF)1-alpha /Angiopoietins (Ang) signaling cascade that triggers pathological neoangiogenesis. Specifically, it has been established in CF-LVAD recipients that the increased levels of Ang-2, decreased Ang-1 and resultant increase in the ratio of Ang-2/Ang-1, presents angiogenic switch that may favor GIAD development. We have recently shown that use of digoxin, a potent inhibitor of HIF1-alpha, is associated with a significant reduction in GIAD related GIB in CF-LVAD patients. We now hypothesize that dysregulation of Ang-2 and Ang-1 levels in patients with CF-LVADs can be restored by digoxin treatment. Methods Blood samples were collected from 10 patients supported with CF-LVAD before and 2 weeks after they were started on digoxin. Ang-1 and Ang-2 was measured in patients’ serum by ELISA. Statistical difference between the groups was tested with paired t-test. Results Digoxin treatment in CF-LVAD patients decreased Ang-2 (14.1 to 8.8 ng/ml, p=0.015) and increased Ang-1 levels (11.6 to 29.8 ng/ml, p=0.002), reversing angiogenic switch (Fig.1). Conclusion Digoxin may restore angiogenic equilibrium in patients supported by CF-LVADs. The relevance of this finding for development of GIB needs to be prospectively studied.

Purpose The pre-operative pulmonary artery pulsatility index (PAPi) is associated with severe right ventricular failure (RVF) after LVAD implantation. We set out to assess how the PAPi trends pre- to post-operatively in patients with and without severe RVF. Methods A single-center retrospective study of 230 patients who received a continuous-flow durable LVAD between 1/2006 and 9/2016. PAPi was defined as: [(PA systolic - PA diastolic) ÷ RA pressure]. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started after 14 days of implant, RVAD placement during implant admission, and death from RVF during implant admission. The hemodynamics pre-implant and post-operatively at 6, 24, and 72 hours were examined. Results In our 230-patient cohort, 62 patients (27%) were found to have severe RVF. Patients with severe RVF had a lower pre-operative (p-value = 0.04), 6-hour post-LVAD (p-value Conclusion The PAPi declines significantly post-operatively in patients with severe RVF and without severe RVF at 6 and 24 hours. For patients with severe RVF, the PAPi significantly improves from 6 to 72 hours post-operatively.

Purpose Although intravenous anticoagulation is the mainstay medical therapy employed during CF LVAD thrombosis, the comparative impact of indirect thrombin inhibition with unfractionated heparin (UH) and direct thrombin inhibition with bivalirudin (BV) is unknown. Methods We conducted a single center review of all patients with a Heart Mate(HM) II who were admitted for suspected device thrombosis (SDT) from September 2011 to September 2018. Device thrombosis was suspected due to elevated outpatient lactate dehydrogenase (LDH), evidence of systemic emboli, or device alarms. After admission, patients were categorized into those receiving UH or BV. Crossovers were excluded. Freedom from device exchange was calculated with Kaplan Meier analysis. Results Twenty-three patients were admitted for SDT, of whom 13 received UH and 10 received BV. There were no differences in age (UH: 49.2 vs. BV: 46.9 years, p=0.60) and time from implant to SDT (UH: 10.3 vs. BV: 10.4 months, p=0.98). LDH remained elevated after UH (879, IQR: 755-1049 to 1028, IQR: 550-1438 U/L, p=0.34) but dropped with BV (839, IQR: 733-914 to 453, IQR: 352-465 U/L, p=0.002). During the follow up period, there was a lower likelihood of a device exchange in patients treated with BV (HR: 0.28, 95% CI: 0.09-0.89, p=0.04, figure 1). Conclusion In this sample of HM II patients, intravenous direct thrombin inhibition was more effective in treating device thrombosis.

Purpose Neutrophil to lymphocyte ratio (NLR), calculated from a CBC, is a marker of systemic inflammation and long-term risk in chronic illness, including heart failure (HF). Vasoplegia syndrome is a severe vasodilatory shock state after cardiac surgery. Patients undergoing heart transplantation (HTx) may be at an increased risk of vasoplegia due to inflammatory cytokine release secondary to HF. The role of NLR as a predictive marker for vasoplegia in patients undergoing HTx has not been studied. Methods Retrospective review of consecutive patients who underwent HTx from 7/2016 to 7/2018. Patients with conditions or treatments known to affect WBC count were excluded. Pre-HTx NLR was calculated from day of HTx and stratified by tertile. Vasoplegia was defined as vasopressor administration for > 24 hours to maintain mean arterial pressure > 65 mmHg for hypotension not attributed to other etiologies within 48 hours of HTx. The primary outcome was rates of vasoplegia between tertiles. Results 78 patients underwent HTx of which 70 met inclusion criteria. 18 patients had vasoplegia. Vasoplegia occurred in 8.7% (n=2) in the 1st tertile, 25% (n=6) in the 2nd tertile and 43.4% (n= 10) in the 3rd tertile (comparison 1st vs 3rd tertile, p=0.04) (Figure). In a multivariate analysis, adjusted for prior LVAD, patients in the 3rd tertile had higher rates of vasoplegia (adjusted OR 2.47, 95% CI 1.87-4.55) compared to the 1st. Mean NLR in patients without vasoplegia was 3.68±0.48 compared to 6.72±1.7 in patients with vasoplegia (p=0.019). There was no demographic or medical comorbidity difference other than hypothyroidism (p=0.04) between groups. Conclusion Vasoplegia is associated with elevated pre-HTx NLR compared to patients without vasoplegia. Chronic inflammation due to HF may play a role in the development of post-HTx vasoplegia. NLR is an inexpensive tool which clinicians may use pre-HTx to stratify which patients are at an increased risk of development of vasoplegia post-HTx.

Purpose The American Society of Transplantation has recently called for better risk stratification of donor hearts based on hepatitis C virus (HCV) antibody (Ab)/NAT status, advised to consider NAT negative (non-viremic) hearts noninfectious, and underscored the need for more research before HCV NAT+ (viremic) hearts can be used routinely. We examined early trends in utilization rates and outcomes of HCV donor hearts based on Ab and NAT status. Methods Between 8/2015 and 6/2018, we identified 29,225 donors with HCV Ab/NAT status and organ disposition in UNOS (for utilization trends). After excluding multi-organ and re-transplants, 7260 adult heart transplantation (HT) recipients were used to analyze baseline donor/recipient characteristics and outcomes in different donor HCV Ab/NAT categories. Results During the study period, the acceptance rates for HCV Ab+/NAT- donor hearts increased from 1.4% to 23.4%, Ab+/NAT+ from 0.6% to 26.0% and Ab-/NAT+ from 0% to 9.1% (p Conclusion Even though infectious risk starkly differs and long-term outcomes are unclear in the era of DAAs, we found a significant and near identical increase in utilization of both HCV viremic (NAT+) and non-viremic (Ab+/NAT-) donor hearts. Early survival was similar to recipients of HCV Ab-/NAT- donor hearts.

Purpose Early identification of right ventricular failure (RVF) after LVAD implantation is critical to reducing morbidity and mortality. The pre-operative pulmonary artery pulsatility index (PAPi) is associated with severe right ventricular failure (RVF) after LVAD implantation. We set out to assess if the PAPi in the immediate post-operative period is also predictive of severe RVF. Methods A single-center retrospective study of 230 patients who received a continuous-flow durable LVAD between 1/2006 and 9/2016. PAPi was defined as: [(PA systolic - PA diastolic) ÷ RA pressure]. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started after 14 days of implant, RVAD placement during implant admission, or death from RVF during implant admission. The hemodynamics pre-implant and post-operatively were documented. A multivariate analysis for predictors of severe RVF was performed, and ROC curves were created. Results In our 230-patient cohort, 62 patients (27%) were found to have severe RVF. Patients in the severe RVF group had higher INTERMACS profile, were more likely to receive pre-operative vasopressors, have lower total bilirubin and lower PAPi. The multivariable model (which included age, INTERMACS level, creatinine over 1.5 mg/dL, total bilirubin over 2.5 mg/dL, and gender) found that a PAPi 16 at 6 hours post-op (OR 3.1 [1.1, 8.6], p = 0.03, n = 208) were significant predictors of severe RVF. The pulmonary artery (PA) pressure at 6 hours and the CVP, PAPi, and PA pressure at 24 hours were not predictive of severe RVF in our model. A PAPi 16 (ROC c-statistic 0.71) at 6 hours post-op. Conclusion The PAPi at 6 hours is a significant predictor of severe RVF and adds value to standard hemodynamic measurements.

Purpose CAV has an immunological component and continues to limit long term outcomes in heart transplantation (HT). Smaller single center studies have suggested that induction with r-ATG may reduce development of CAV. We evaluated the association of induction with r-ATG, Basiliximab (BxB), or ‘no induction’ and CAV in HT recipients, traditionally considered not highly sensitized [pre-transplant panel reactive antibody (PRA) class 1 and class 2 ≤ 10%]. Methods Between 6/2004 and 03/2015, we identified 4,654 adult HT recipients in UNOS who either had induction with r-ATG, BxB or ‘no induction’ at the time of HT, and had information on pre-HT PRA levels and CAV. Donor age above 55 years or structural abnormalities, multi-organ or repeat transplants were excluded. The 3 groups: r-ATG (n=644), BxB (n=991), no induction (n=3019) were compared for baseline donor/recipient characteristics and CAV. Results Overall, pre-transplant PRA 1 and 2 levels were 0.5±1.7% and 0.3±1.3% respectively. Compared to no induction or BxB, HT recipients in r-ATG group were slightly younger (53 vs 55 vs 56 yrs), more black race (23% vs 16% vs 22%), less Status 1A (49% vs 59 vs 62%). BxB group had more recipients with creatinine >1.5 (24% vs 23% in r-ARG vs 17% no-induction) (all p Conclusion Although rates of CAV were higher in our specific cohort than previously reported for the overall HT population, r-ATG was associated with lower CAV in HT recipients who are traditionally considered to be not highly sensitized.

Purpose Pre-transplant amiodarone and left ventricular assist device (LVAD) has been shown to be independently associated with severe PGD; however, the interaction between both exposures has not been examined. We evaluated the relationship of pre-transplant amiodarone, left ventricular assist device and severe PGD. Methods Single center, retrospective cohort, adult (age > 18) OHT patients between 2006-2018. Severe PGD was defined as left or right or biventricular failure requiring mechanical circulatory support within 24 hours of OHT. Pre-transplant amiodarone use was within 3 months preceding OHT. Patients were grouped by presence (denoted +) or absence (denoted -) of LVAD and amiodarone. Results A total of 257 patients were transplanted during the study period, mean age 53.8 years, 73 (28.4%) females, 162 (63%) BTT and 90 (35%) patients had amiodarone use. There were 21 (8.2%) patients with severe PGD. The prevalence of severe PGD was highest in LVAD+/Amiodarone+ group (20.3%), followed by LVAD+/Amiodarone - (6.8%), LVAD-/Amiodarone+ (3.2%) and LVAD-/Amiodarone- (1.6%), p=0.0008 (Figure 1). Multivariate logistic regression analysis of pre-operative risk factors revealed LVAD (OR 5.95; 95% CI 1.23-28.52; p=0.03), amiodarone (OR 3.52; 95% CI 1.26-9.87; p=0.02), recipient diabetes (OR 3.36; 95% CI 1.11-10.21; p=0.03) and recipient hypertension (OR 0.22; 95% CI 0.08-0.61; p=0.04) were independently associated with severe PGD. Additive interaction analysis of amiodarone and LVAD was inconclusive due to the small sample size [relative excess risk due to interaction 8.13; 95% CI -10.37-26.2; p=0.39, attributable proportion 0.66; 95% CI 0.19-1.13; p=0.01 and synergy index 3.61; 95%CI 0.49-26.32; p=0.21]. Conclusion LVAD and amiodarone are associated with severe PGD, however the interaction of both exposures requires further analysis with a larger cohort.

Objective To evaluate the mean platelet volume (MPV) and its correlation with cardiovascular risk in type 2 diabetic patients. Background Platelet functions have important roles in the development of vascular complications in diabetic patients. Platelets with increased volume have increased activity compared to smaller ones, therefore, MPV is used as a marker for platelet activity. Patients and methods A cross-sectional analytical study was done on a group of 60 type 2 diabetic patients divided into group I, included 23 cases without cardiovascular disease, group II, included 37 cases with cardiovascular disease, and group III, included 20 healthy people as the control group. All patients attended the Endocrine and Diabetes Clinic in Menoufia University during the period from 2015 to 2016. Comparisons of fasting blood sugar, 2-h post prandial (2HPP), lipid profile, and MPV were tested. Results Diabetic patients with cardiovascular disease had a higher MPV (11.08 ± 1.39) than diabetic patients without cardiovascular disease (10.53 ± 1.33) and healthy group (8.30 ± 1.62). There was a significant difference between the studied groups regarding MPV, fasting blood sugar, 2HPP and low density lipoprotein cholesterol, and hemoglobin A1c. In addition, MPV showed a significant positive correlation with fasting blood sugar, 2HPP, hemoglobin A1c, serum cholesterol, and low density lipoprotein cholesterol. Whereas, MPV was not correlated with serum glyceride and high-density lipoprotein cholesterol. Conclusion Platelet dysfunction occurs in diabetic patients and this is demonstrated by higher than normal MPV. MPV was found to carry a risk of development of cardiovascular disease in these patients.

Social networks can offer many services to the users for sharing activities events and their ideas. Many attacks can happened to the social networking websites due to trust that have been given by the users. Cyber threats are discussed in this paper. We study the types of cyber threats, classify them and give some suggestions to protect social networking websites of variety of attacks. Moreover, we gave some antithreats strategies with future trends.

Electronic voting has attracted much interest recently and a variety of schemes have been proposed. Generally speaking, all these schemes can be divided into three main approaches: based on blind signature, based on mix networks and based on homomorphism encryption. Schemes based on blind signature are thought to be simple, efficient, and suitable for large scale elections. With the help of networking and internet we can easily replace the traditional election process with the electronic voting system. In the proposed cryptographic technique we are implementing new blind signature based on linear matrix function and modulation. The new scheme fully conforms to the requirement of large scale election such as privacy, fairness and security. The voter's private key for digital signature is protected by using linear square matrix based on block cipher algorithm and it can be make many combination so that only valid voter can use it. In the cryptography history, block cipher used in symmetric key algorithm, this is first time we are introducing block cipher as a public key algorithm.

Background Centre volume is an important determinant of outcomes in patients requiring complex medical treatments or surgical procedures. Heart failure hospitalisation (HFH) has become an increasingly complex and resource intensive clinical event. We evaluated the effect of centre volume on mortality and costs in patients with HFH. Methods This was a retrospective registry-based analysis of adult patients discharged with a primary diagnosis of HF from hospitals across New York (NY) State over a 5-year period, between January 2009 and December 2013, using the Statewide Planning and Research Cooperative System inpatient discharge files. The primary outcome of interest was in-hospital mortality. All patients were followed from the day of admission to either in-hospital death or discharge alive. Results 300 972 HFHs from 198 facilities across NY State were included. Five-year centre volume was associated with a decrease in in-hospital mortality in unadjusted (HR=0.872, 95% CI 0.863 to 0.881, p Conclusions Higher centre volume was associated with lower HFH mortality but increased HFH costs and increased cardiac procedures in a cohort of Medicare and non-Medicare beneficiaries.

The purpose of this review is to highlight recent advances and challenges in the clinical implementation of continuous flow left ventricular assist devices (CF LVADs) in patients with advanced heart failure. Post approval studies of CF LVAD therapy continue to show a progressive improvement in survival and reduction in adverse events. Major trials are ongoing to compare outcomes of an axial flow device (Heart Mate II) and smaller centrifugal flow pumps (HeartWare VADs and Heart Mate III). Numerous studies have investigated strategies to reduce major hematologic and neurologic adverse events by evaluating hemolysis, antithrombotic therapy, and blood pressure control. This review will present the current findings that are centered around the impact of CF LVADs on improving survival and reducing adverse events through an evolution in management and design.

Background— Despite a limited supply of organs, only 1 in 3 potential donor hearts is accepted for transplantation. Elevated donor troponin levels have generally been considered a contraindication to heart transplantation; however, the data supporting this practice are limited. Methods and Results— We identified 10 943 adult (≥18 years) heart transplant recipients in the United Network of Organ Sharing (UNOS) database with preserved donor left ventricular ejection fraction (≥50%) and where peak donor troponin I values were available. When analyzed as a continuous variable, there was no association between peak donor troponin levels and recipient mortality up to 1 year follow-up in unadjusted (hazards ratio, 0.999; 95% confidence interval, 0.997–1.002; P =0.856) and adjusted Cox models (hazards ratio, 1.000; 95% confidence interval, 0.997–1.002; P =0.950). Next, we divided the entire cohort into 3 groups based on donor troponin I values: 10 ng/mL (n=361). Using unadjusted and adjusted Cox models and Kaplan–Meier analysis, there was no significant difference in recipient mortality at 30 days, 1 year, 3 years, or 5 years between the 3 groups. Similarly, cardiac allograft vasculopathy up to 5 years and primary graft failure up to 30 days of follow-up post transplant did not differ between the 3 donor troponin groups. The median length of hospital stay post transplant was also similar across groups. Conclusions— Elevated donor troponin I levels in the setting of preserved left ventricular ejection fraction were not associated with intermediate-term mortality, cardiac allograft vasculopathy, or primary graft failure rates in hearts accepted for transplantation. This finding could help expand the donor pool.

Objectives This study sought to determine whether the nasal mucosa can serve as a surrogate for evaluating arteriovenous malformations (AVMs) related gastrointestinal (GI) bleeding in patients supported by continuous-flow left ventricular assist devices (CF LVADs). Background Bleeding from the mucosal surfaces of GI tract, particularly AVMs, is the most common complication of CF LVAD support. The pathophysiology of AVM formation during CF LVAD support is of critical interest yet poorly understood; in large part because of the length and accessibility of the GI tract. Nasal endoscopy is a minimally invasive, bedside test giving access to a mucosal surface possibly representative of the GI tract. Methods Eighty subjects (35 with CF LVAD, 30 with heart failure reduced ejection fraction [HFrEF], and 15 controls without heart failure) underwent nasal endoscopy for systematic evaluation of the intranasal mucosa for the presence of hypervascularity (HV). Patient records were reviewed for episodes and etiology of GI bleeding. Results Nasal HV was present in 63%, 57%, and 20% of the LVAD, HFrEF, and control groups, respectively (p = 0.018). Although the prevalence was similar, the severity of nasal HV was significantly higher in the CF LVAD group compared with the HFrEF group. Of the baseline characteristics in the entire cohort, only a history of heart failure was associated with HV (odds ratio: 4.8; 95% confidence interval: 1.02 to 22.31; p = 0.040) in adjusted logistic regression modeling. HV was strongly associated with GI bleeding in the CF LVAD cohort: the incidence was 32% in subjects with HV compared with 0% in subjects with normal mucosa (p = 0.023). Conclusions In this pilot study, HV of the nasal mucosa was associated with GI bleeding in subjects with CF LVADs. Nasal endoscopy has significant potential to further investigation into mechanisms of bleeding and risk stratification during CF LVAD support.

Background: There has been a long-standing debate in the role of hormone replacement therapy (HRT) and migraines as risk factors for ischemic stroke. HRT are considered a risk factor for migraines. The risk of ischemic stroke may increase as the severity of migraines increases in patients that are currently using HRT. Methods: We analyzed the data for 82,208 women aged 50 - 79 years who were enrolled in the observational arm of the Women’s Health Initiative Study. We determined the risk of ischemic stroke in participants with migraines who had current Hormone replacement therapy (HRT) (unopposed estrogen and/or estrogen plus progesterone), past HRT, and no HRT. We further dichotomized participants with migraines into participants who experienced an increase in migraine severity of one grade or more from baseline on the third-year follow up visit and participants who experienced no change or a decrease in migraine severity from baseline on the third-year follow up visit. The relative risk of developing ischemic stroke was compared between participants who were currently on HRT and participants who were either previously on HRT or never had HRT. Results: Out of the 82,208 women, 37680 (45.8%) were currently using HRT and 44528 (54.2%) were either past users or had never used HRT therapy. Compared with never or past users of HRT, rate of increase in severity of migraines was significantly higher among those who were currently on HRT therapy (17.3% versus 18.7% versus 20.6%, respectively, p Conclusions: Patients that are current users of HRT that have an increase in severity of one grade or more of migraines are shown to have an increased risk of ischemic strokes. Future studies are required to further investigate these correlations.

Background: The incidence of pregnancy in advanced age among women is increasing due to availability of assisted reproduction although the complication rates associated with pregnancy are higher. The long-term health consequences in women with pregnancy in advanced age is not known. We determine the effect of pregnancy in advanced age on occurrence of cardiovascular events in a large cohort of post-menopausal women. Methods: We analyzed the data for 72,221 women aged 50-79 years who were enrolled in the observational arm of the Women's Health Initiative Study. We determined the effect of pregnancy in advanced age (last pregnancy at age≥40 year) on risk of ischemic stroke, hemorrhagic stroke, myocardial infarction, and cardiovascular death over a mean period (± standard deviation [SD]) of 12±1 years using Cox Proportional Hazards analysis after adjusting for potential confounders. Results: A total of 3306 (4.6%) of the 72,221 participants reported pregnancy in advanced age. Compared with pregnancy in normal age, the rate of ischemic stroke (2.4% versus 3.8%, p Conclusions: Women with pregnancy in advanced age have a higher risk for hemorrhagic stroke in post-menopausal period.

Background — Hematologic adverse events are common during continuous flow left ventricular assist device support; yet, their relation to antiplatelet therapy, including aspirin (ASA) dosing, is uncertain. Methods and Results— A single-center retrospective review of all patients supported by a continuous flow left ventricular assist device (Heart Mate II) from June 2006 to November 2014 was conducted. Patients were categorized into 3 groups: (1) ASA 81 mg+dipyridamole 75 mg daily (n=26) with a target international normalized ratio (INR) of 2 to 3 from June 2006 to August 2009; (2) ASA 81 mg daily (n=18) from September 2009 to August 2011 with a target INR of 1.5 to 2; and (3) ASA 325 mg daily from September 2011 to November 2014 with a target INR of 2 to 3 (n=70). Hemorrhagic and thrombotic outcomes were retrieved ≤365 days after implantation. Cumulative survival free from adverse events was calculated using Kaplan–Meier curves and Cox proportional hazard ratios were generated. Hemorrhagic events occurred in 6 patients on ASA 81 mg+dipyridamole (26%; 0.42 events per patient year; mean INR at event, 2.2), 4 patients on ASA 81 mg (22%; 0.38 events per patient year; mean INR at event, 2.0), and in 38 patients on ASA 325 mg (54%; 1.4 events per patient year; mean INR at event, 2.2); P =0.004. Patients on ASA 325 mg had a higher adjusted hazard ratio of 2.9 (95% confidence interval, 1.2–7.0 versus ASA 81 mg+dipyridamole; P =0.02) and 3.4 (95% confidence interval, 1.2–9.5 versus ASA 81 mg; P =0.02) for hemorrhagic events. Thrombotic events rates were not different between groups. Conclusions— High-dose ASA in Heart Mate II patients treated concomitantly with warfarin is associated with an increased hazard of bleeding but does not reduce thrombotic events.

Bu çalışma, Ankara Numune Eğitim ve Araştırma Hastanesi'nde duygusal zekâpuanları ve liderlik davranışları algısı düzeylerini belirlemek, duygusal zekâ puanları veliderlik davranışları algısı düzeylerinin sosyo-demografik özelliklere göre farklılıklarınısaptamak ve duygusal zekâ puanları ve liderlik davranışları arasındaki ilişkiyideğerlendirmek amacıyla yapılmıştır.Bu tanımlayıcı bir araştırmadır. Araştırmanın evrenini, Ankara Numune Eğitim veAraştırma Hastanesi'nde görev yapan 735 hemşire oluşturmuş, çalışmada 450 çalışanaulaşılmıştır. Katılımcıların, sosyo-demografik verileri için kisisel bilgi formu, DuygusalZekâ Ölçeği (Schutte tarafından geliştirilen Duygusal Zekâ Ölçeği), LiderlikDavranışları Ölçeği (Bass tarafından geliştirilen Çok Faktörlü Liderlik Ölçeği-MLQ)ölçüm araçları olarak kullanılmıştır. Araştırma sonucunda hemşirelerin duygusal zekânınalt boyutları puan ortalamalarının yüksek olduğu söylenebilir. Ancak duygusal zekânın(duyguların kullanımı) alt boyutu orta düzeyde kalmaktadır. Hemşirelerin liderlikdavranışların algısı alt boyutlarının ortalaması incelendiğinde, hemşirelerin liderlikdavranışları algısı alt boyutları puan ortalamalarının yüksek olduğu söylenebilir. Enyüksek alt ölçek puan ortalamalarının dönüşümcü liderlik davranışları algısı üzerindeolduğu gözlenmiştir.Çalışmada, hemşirelerin duygusal zekâlarının özellikleri ve sosyo-demografiketkenlere göre değişiklikleri incelenmiştir. Analiz sonucunda, hemşirelerin duygusalzekâ (iyimserlik/ruh halinin düzenlenmesi) puan ortalaması görev ve gelire göre farklılıkgöstermektedir. Hemşirelerin duygusal zekâ (duyguların değerlendirilmesi) puanortalaması cinsiyete farklılık göstermektedir. Hemşirelerin duygusal zekâ (duygularınkullanımı) puan ortalaması medeni durum, öğrenim durumu ve mesleki kıdeme görefarklılık göstermektedir.Çalışmada, hemşirelerin liderlik davranışlarının algısı ve sosyo-demografiketkenlere göre değişiklikleri incelenmiştir. Analiz sonucunda, hemşirelerin liderlikdavranışları algısı (dönüşümcü liderlik) puan ortalaması yaş, mesleki kıdem, kurumdaçalışma süresi, görev, gelire göre farklılık göstermektedir. Hemşirelerin liderlikdavranışları algısı (etkileşimci liderlik) puan ortalaması öğrenim durumu, yaş, meslekikıdem, kurumda çalışma süresi, göreve göre farklılık göstermektedir. Hemşirelerinliderlik davranışları algısı (tam serbestlik) puan ortalaması mesleki kıdem, çalışma şekli,gelire göre farklılık göstermektedir.Çalışmada, duygusal zekâ puanların boyutları ile liderlik davranışların algısıboyutları arasında istatistiksel olarak anlamlı bir ilişki olup olmadığı incelemiştir. Analizsonucunda, iyimserlik halinin düzenlenmesi boyutunun ilişkin zekâ düzeyleri iledönüşümcü liderlik davranışları algısı arasında pozitif yönlü orta düzeyde anlamlı birilişki bulunmuştur. İyimserlik halinin düzenlenmesine ilişkin zekâ düzeyleri ileetkileşimci liderlik davranışları algısı arasında pozitif yönlü orta düzeyde anlamlı birilişki bulunmuştur. İyimserlik halinin düzenlenmesine ilişkin zekâ düzeyleri ile tamserbestliğe ilişkin liderlik davranışları algısı arasında pozitif yönlü düşük düzeydeanlamlı bir ilişki bulunmuştur.Duyguların değerlendirmesine ilişkin zekâ düzeyleri ile dönüşümcü liderlikdavranışları algısı arasında pozitif yönlü düşük düzeyde anlamlı bir ilişki bulunmuştur.Duyguların değerlendirmesine ilişkin zekâ düzeyleri ile etkileşimci liderlik davranışlarıalgısı arasında pozitif yönlü çok düşük düzeyde anlamlı bir ilişki bulunmuştur.Duyguların değerlendirmesine ilişkin zekâ düzeyleri ile tam serbestliğe ilişkin liderlikdavranışları algısı arasında negatif yönlü çok düşük düzeyde anlamlı olmayan bir ilişkibulunmuştur.Duyguların kullanımına ilişkin zekâ düzeyleri ile dönüşümcü liderlik davranışlarıalgısı arasında negatif yönlü düşük düzeyde anlamlı bir ilişki bulunmuştur. Duygularınkullanımına ilişkin zekâ düzeyleri ile etkileşimci liderlik davranışları algısı arasındanegatif yönlü düşük düzeyde anlamlı bir ilişki bulunmuştur. Duyguların kullanımınailişkin zekâ düzeyleri ile tam serbestliğe ilişkin liderlik davranışları algısı arasındanegatif yönlü düşük düzeyde anlamlı bir ilişki bulunmuştur.Anahtar Kelimeler: Duygusal zekâ, Hemşire, Liderlik The aim of this study was to determine the level of emotional intelligence skills andleadership behavioral perception among nurses and to determine the level of differencesfor emotional intelligence skills and leadership behaviors according to sociodemographicfactors and to evaluate the relationship between emotional intelligenceskills and leadership behaviors among nurses working at Ankara Numune Teaching andTraining Hospital.This is a descriptive study. The population of the study consist of 735 nurses whowork at the hospital at the period which this study took a place. The sample of the studyconsists of 450 nurses. (61.2%) of the total population have been reached. In order tocollect the data, personal information form (for socio-demographic features), Emotionalintelligence scale (emotional Intelligence Scale which was developed by Schutte),Leadership scale (Multifactor Leadership Questionnaire-MLQ which developed byBass) were used. The results indicate that the average scores for nurse's emotionalintelligence skills components was high (above-average) except for one emotionalintelligence component which known as the (utilizations of emotions) was in average.For the leadership behaviors scale, the results indicate that the average scores for nurse'semotional intelligence skills components was high (above-average) and the highest scorewas giving for (transformational leadership) component.In this study, the emotional intelligence features was evaluated according to nurse'ssocio-demographic factors. The results indicate that emotional intelligence (optimism/mood regulation) component's mean points differ according to nurse's duties andincome meanwhile (appraisal of emotions) component's mean points differ according tonurse's gender. The results indicate also that emotional intelligence (utilizations ofemotions) component's mean points differ according to nurse's level of education,marital status and seniority.In this study also, leadership behavioral perception features was evaluatedaccording to nurse's socio-demographic factors. The results indicate that leadershipbehavior (transformational leadership) component's mean points differ according tonurse's age, seniority, working time in one's organization, duties and income. The resultsalso had shown that the (transactional leadership) component's mean points differaccording to nurse's age, level of education, seniority, working time in one'sorganization, and duties. This study's results also had shown that (laissez-faire leadership) component's mean points differ according to nurse's seniority, shiftspatterns, and income.In this study, the relationship between emotional intelligence skills components andleadership behavioral perception components was evaluated. The results indicate thatone of the emotional intelligence components (optimism / mood regulation) were relatedpositively to all leadership behavior's (transformational leadership, transactionalleadership, laissez-faire leadership).and the other emotional intelligence componentwhich known as (appraisal of emotions) were related positively to only (transformationalleadership) and (transactional leadership).Key words: Emotional intelligence, Leadership, Nurse 183

Background Adaptation to altitude leads to beneficial physiologic changes that improve oxygen delivery and utilization by the periphery. Athletes have used simulated altitude enclosures as part of their training regimen to improve exercise performance. We hypothesized that changes due to acclimatization would also be beneficial for patients with heart failure (HF). We report the results of a pilot study of altitude exposure in patients with chronic HF. Methods and Results Subjects with chronic stable HF, left ventricular ejection fraction (LVEF) ≤35%, on optimal medical therapy were enrolled and underwent simulated altitude exposure for 10 sessions, each 3–4 hours, over a period of 22 days. Starting altitude was 1,500 m and was increased by 300 m with each subsequent session to a maximum altitude of 2,700 m. Peak oxygen consumption, 6-minute walk distance (6MW), skeletal muscle strength, quality of life scores, LVEF, and hematologic parameters were measured at baseline and 48 hours and 4 weeks after the final session. Twelve subjects (median age 52.5 y, ejection fraction 31.7%) successfully completed the protocol without any adverse effects. Peak oxygen consumption significantly improved after altitude sessions from 13.5 ± 1.8 to 14.2 ± 1.9 mL kg −1 min −1 ( P = .036) and remained elevated after 4 weeks. There were significant improvements in exercise time, 6MW, skeletal muscle strength, and quality of life scores and a trend toward improvement in LVEF after completion of altitude sessions, which were sustained after 1 month. Conclusions Simulated altitude exposure up to 2,700 m is safe and well tolerated in patients with chronic stable HF and may have beneficial effects on exercise performance, muscular strength, and quality of life.

Kikuchi-Fujimoto Disease or Necrotizing Lymphadenitis is a rare, benign, self-limiting disease. It usually effects young females in the third decade of life. The most common presentation is cervical lymphadenopathy, though the etiology of the disease is still controversial. Clinical findings, histological diagnosis and immunohistochemistry help in diagnosis. Once diagnosed, steroids have been found to alleviate symptoms in patients with systemic manifestations. Antibiotics should not be prescribed until infective element is identified. We report the case of a female patient who presented with tender cervical lymphadenopathy. She was diagnosed on excision biopsy of one of her lymph nodes. Anti-inflammatory drugs were started but the disease relapsed briefly after. Her symptoms have improved remarkably after initiation of steroid therapy, since her relapse.

Introduction The pulmonary artery pulsatility index (PAPi) is an emerging hemodynamic marker correlated with severe post-LVAD RVF in single-center cohort studies. We set out to examine if this is generalizable in a multi-institutional analysis. Hypothesis The preoperative PAPi correlates with RVF as defined by new INTERMACS criteria (INTERMACS-RVF), severe RVF, and death at 1-year. Methods We performed a dual-center retrospective study of 404 patients from Ohio and New York who received a continuous-flow durable LVAD and had a pre-operative PAPi measurement. The PAPi was defined as: [(PA systolic - PA diastolic) ÷ RA pressure]. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started 14 days after implant, RVAD placement during implant admission, and death from RVF during implant admission. A multivariate analysis of predictors of post-LVAD severe RVF was conducted. A survival analysis was performed to examine pre-operative PAPi as a predictor of 1-year mortality. Results In our cohort of 404 patients, 84 (21%) had severe RVF. Multivariable logistic regression for severe RVF (controlling for age, INTERMACS level, creatinine, and gender) showed that creatinine > 1.5 (OR 2.24, p=0.002, 95% CI [1.43-4.42]) and total bilirubin > 2.5 (OR 2.87, p=0.004, 95% CI [1.39-5.93]) significantly increased the odds of severe RVF, and a PAPi Figure 1 ) and INTERMACS-RVF (c-statistic=0.63) were similar. With respect to survival, the final multivariable model (controlling for age, gender, and ethnicity) showed a PAPi Conclusion PAPi

Introduction Preoperative cardiac ascites has been shown to be a predictor of mortality in the latest INTERMACS report. However, it has not been shown to be an independent risk factor for the development of RVF after LVAD implantation. Hypothesis Pre-operative ascites on imaging during implant admission is associated with post-operative RVF. Methods We performed a single-center retrospective study of 153 patients who received a continuous-flow durable LVAD between 1/2006 and 12/2016 and who also had preoperative abdominal ultrasound or CT aduring implant admission. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started 14 days after implant, RVAD implant, and death from RVF. The severity of ascites was extracted from the radiology reports and was graded as either none/trace, mild, moderate, or severe. A multivariate analysis of pre-operative ascites stratified by severity and post-implant RVF was performed. Results In our 153 patient cohort, 43 (28.1%) were found to have significant ascites, with 35 (22.9%) having mild ascites, 8 (5.6%) having moderate ascites, and 0 having severe ascites. Patients with ascites had higher preoperative total bilirubin, lower platelet count, higher mean RA pressure, higher mean PA pressure, lower pulmonary artery pulsatility index (PAPi), higher PCWP, and higher mortality rate, p Table 1 ). The multivariable model (which included age, INTERMACS level, creatinine, gender, and total bilirubin) found that preoperative ascites (OR 1.98, 95% CI [1.02 - 3.81], p = 0.04) and total bilirubin (OR 1.50, 95% CI [1.07 - 2.10], p = 0.018) were independent predictors of post-implant RVF. The ROC curve of ascites and post-operative RVF had a c-statistic of 0.72 ( Figure 1 ). Conclusion The preoperative presence of ascites correlates with post-operative RVF. Abdominal imaging could be useful in further risk stratifying patients for post-implant RVF.

Introduction Early RVF after LVAD implant has been studied using varying definitions. We set out to compare the new INTERMACS post-LVAD RVF criteria and traditional severe RVF definitions in our multi-institutional cohort. Hypothesis The INTERMACS RVF and severe RVF definition will both show increased mortality at 1-year. Methods We performed a dual-center retrospective study of 471 patients who received a continuous-flow durable LVAD and data available to assess RVF severity. The new INTERMACS RVF definition stratifies RVF into mild, moderate, severe, and acute-severe. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started after 14 days of implant, RVAD placement during implant admission, and death from RVF during implant admission. A survival analysis of the INTERMACS RVF and severe RVF definitions was performed. A multivariate analysis using clinical markers associated with post-LVAD mortality was then completed to assess the independent effect of the RVF definitions. Results Of the 471 patients, 100 (21%) had severe RVF. Stratified by INTERMACS-RVF, 279 (59%) had no RVF, 37 (8%) had mild RVF, 53 (11%) had moderate RVF, 57 (12%) had severe RVF, and 47 (17%) had acute-severe RVF. Our multivariate model (adjusted for age, gender, and ethnicity) for predictors of 1-year mortality showed that PAPi Conclusion Our multi-institutional cohort shows that severe RVF and INTERMACS RVF severe and acute-severe predict mortality at 1-year, and notably shows that mild and moderate INTERMACS RVF do not predict mortality. The new INTERMACS classification of RVF provides more granularity in stratifying RVF and may be more clinically applicable.

Hydralazine-isosorbide dinitrate (H-ISDN) carries an indication for treating systolic heart failure (HF). Hydralazine-isosorbide mononitrate (H-ISMN) does not carry this indication, but is used nonetheless as ISMN is once a day, while ISDN is three times a day. How effective H-ISMN is compared to H