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JACC : Heart Failure
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     ISSN (Online) 2213-1779
     Published by American College of Cardiology Foundation Homepage  [1 journal]
  • Low Bone Mineral Density Predicts Incident Heart Failure in Men and Women
           The EPIC (European Prospective Investigation Into Cancer and
           Nutrition)–Norfolk Prospective Study
    • Authors: Pfister R; Michels G, Sharp SJ, et al.
      Abstract: ObjectivesIt is unknown whether bone mineral density as a measure of osteoporosis is associated with development of heart failure.BackgroundRecent evidence suggests shared risk factors between heart failure and osteoporosis. Additionally, patients with osteoporosis are at increased risk for cardiovascular disease.MethodsWe examined the prospective association of bone mineral density measured as broadband ultrasound attenuation by quantitative ultrasound of the heel with incident heart failure events in 13,666 apparently healthy persons 42 to 82 years of age participating in the EPIC (European Prospective Investigation into Cancer and Nutrition) study in Norfolk, United Kingdom.ResultsDuring a mean follow-up of 9.3 years, 380 incident cases of heart failure occurred. The risk of heart failure decreased with increasing bone mineral density. The hazard ratios comparing each quartile with the lowest were 0.40 (95% confidence intervals [CI]: 0.27 to 0.59), 0.54 (95% CI: 0.37 to 0.79), and 0.46 (95% CI: 0.32 to 0.68) in analysis adjusting for age, sex, smoking, alcohol consumption, physical activity, occupational social class, educational level, systolic blood pressure, diabetes, cholesterol concentration, and body mass index (p for trend = 0.002), with a 23% risk decrease associated with every increase in 1 standard deviation of bone mineral density (hazard ratio [HR]: 0.77; 95% CI: 0.66 to 0.89). The association was stronger with heart failure without (HR: 0.75; 95% CI: 0.63 to 0.89) than with antecedent myocardial infarction (HR: 0.82; 95% CI: 0.62 to 1.09).ConclusionsWe observed an inverse association between bone mineral density and the risk of heart failure in apparently healthy individuals. Our findings give support for cardiac assessment in people with reduced bone mineral density and warrant further exploration of underlying biological mechanisms linking osteoporosis and heart failure.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • U.S. Donor Heart Allocation Bias for Men Over Women' A Closer Look
    • Authors: Kobashigawa JA.
      Abstract: In this issue of JACC: Heart Failure, Hsich et al. (1) review the Scientific Registry of Transplant Recipients (SRTR) database between 2000 and 2010 and find a greater waitlist mortality for women than for men for status 1A patients. They conclude that the United Network for Organ Sharing (UNOS) donor heart allocation system favors men over women for status 1A patients with an unclear explanation for the difference.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Physician Continuity Improves Outcomes for Heart Failure Patients Treated
           and Released From the Emergency Department
    • Authors: Sidhu RS; Youngson E, McAlister FA.
      Abstract: ObjectivesThe goal of this study was to evaluate the effect of physician continuity for patients with heart failure (HF) treated and released from the emergency department (ED).BackgroundAlthough current guidelines recommend early follow-up after hospital discharge, it is unclear if it is beneficial in patients sent home from the ED and whether this follow-up should be with a familiar physician.MethodsThis was a retrospective cohort of all adults treated and released from 93 EDs in Alberta, Canada, from 1999 to 2009 with a first-time most responsible diagnosis of HF. Cox proportional hazards models with time-varying covariates for post-ED outpatient visits were used.ResultsIn 12,285 patients (mean age 74.9 years), the rate of death or all-cause hospitalization at 6 months was lower in those who saw a familiar physician (37.3%; adjusted hazard ratio [aHR]: 0.89 [95% confidence interval (CI): 0.83 to 0.96]) in the first month versus those with no outpatient visits (58.1%; aHR: 1.00 [referent]) or visits only with unfamiliar physicians (40.2%; aHR: 1.04 [95% CI: 0.94 to 1.15]). Taking into account all outpatient visits over each observation period and excluding those without follow-up, death or hospitalization was less common in those patients being followed up by a familiar physician (aHR of 0.79 [95% CI: 0.71 to 0.89] at 3 months; aHR of 0.86 [95% CI: 0.77 to 0.95] at 6 months; and aHR of 0.87 [95% CI: 0.80 to 0.96] at 12 months compared with unfamiliar physician follow-up). Any follow-up within 30 days of ED release was associated with a lower risk of repeat ED visit or death at 6 months (aHR: 0.78 [95% CI: 0.73 to 0.82] for familiar physicians; aHR: 0.79 [95% CI: 0.72 to 0.86] for unfamiliar physicians).ConclusionsEarly follow-up after an ED visit is associated with better outcomes, particularly if conducted with a familiar physician.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • So Nice to See You Again Physician Continuity and Outcomes for Heart
           Failure ∗
    • Authors: Joynt KE.
      Abstract: In this issue of JACC: Heart Failure, Sidhu et al. (1) set out to determine whether physician continuity improves outcomes for patients with heart failure (HF) treated and released from the emergency department (ED). They report that, indeed, HF patients who are seen by a familiar physician in the first month after an ED visit are significantly less likely to die or to be hospitalized than those patients who see no outpatient physician in the same time frame or those who have visits only with unfamiliar physicians. The size of the associations was impressive, with a 21% lower hazard of repeat ED visit or death for patients with a follow-up visit with a familiar physician compared with an unfamiliar physician.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Body Position and Activity, But Not Heart Rate, Affect Pump Flows in
           Patients With Continuous-Flow Left Ventricular Assist Devices
    • Authors: Muthiah K; Gupta S, Otton J, et al.
      Abstract: ObjectivesThe aim of this study was to determine the contribution of pre-load and heart rate to pump flow in patients implanted with continuous-flow left ventricular assist devices (cfLVADs).BackgroundAlthough it is known that cfLVAD pump flow increases with exercise, it is unclear if this increment is driven by increased heart rate, augmented intrinsic ventricular contraction, or enhanced venous return.MethodsTwo studies were performed in patients implanted with the HeartWare HVAD. In 11 patients, paced heart rate was increased to approximately 40 beats/min above baseline and then down to approximately 30 beats/min below baseline pacing rate (in pacemaker-dependent patients). Ten patients underwent tilt-table testing at 30°, 60°, and 80° passive head-up tilt for 3 min and then for a further 3 min after ankle flexion exercise. This regimen was repeated at 20° passive head-down tilt. Pump parameters, noninvasive hemodynamics, and 2-dimensional echocardiographic measures were recorded.ResultsHeart rate alteration by pacing did not affect LVAD flows or LV dimensions. LVAD pump flow decreased from baseline 4.9 ± 0.6 l/min to approximately 4.5 ± 0.5 l/min at each level of head-up tilt (p < 0.0001 analysis of variance). With active ankle flexion, LVAD flow returned to baseline. There was no significant change in flow with a 20° head-down tilt with or without ankle flexion exercise. There were no suction events.ConclusionsCentrifugal cfLVAD flows are not significantly affected by changes in heart rate, but they change significantly with body position and passive filling. Previously demonstrated exercise-induced changes in pump flows may be related to altered loading conditions, rather than changes in heart rate.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Inside This Issue
    • PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Functional Status and Outcome After Coronary Artery Bypass Grafting
    • Authors: Bittner V.
      Abstract: Physical activity and fitness strongly predict mortality in healthy adults of all ages and in individuals with cardiovascular disease and other health conditions (1). Physical fitness can be assessed by maximal or submaximal exercise testing or approximated by history taking or formal questionnaires that query the ability to perform activities of various intensities. Assessment of the ability to perform activities that require more than 4 metabolic equivalents is recommended pre-operatively for risk stratification in individuals in need of noncardiac surgery (2). Formal cardiopulmonary exercise testing, especially the determination of anaerobic threshold, has been advocated for pre-operative functional assessment (3). Others have suggested that the 6-min walk test can be used when cardiopulmonary exercise testing is not available (4). Functional status is not currently included as a risk marker in the Society of Thoracic Surgeons Risk Calculator for cardiovascular surgery (5).
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Does the UNOS Heart Transplant Allocation System Favor Men Over Women'
    • Authors: Hsich EM; Starling RC, Blackstone EH, et al.
      Abstract: ObjectivesThe aim of this paper was to identify sex differences in survival of patients awaiting orthotopic heart transplantation (OHT).BackgroundWomen have a higher mortality rate while awaiting OHT than men, and the reason has not been fully determined.MethodsWe included all adult patients in the Scientific Registry of Transplant Recipients (SRTR) placed on the OHT waiting list from 2000 to 2010. The primary endpoint was all-cause mortality before receiving OHT, analyzed using time-to-event analysis. Multivariate Cox proportional hazards models were used to evaluate sex differences in survival, with data stratified by United Network for Organ Sharing (UNOS) status at time of listing.ResultsThere were 28,852 patients (24% women) awaiting OHT. This cohort included 6,163 UNOS status 1A (25% women), 9,168 UNOS status 1B (25% women), and 13,521 UNOS status 2 (24% women) patients. During a median follow-up of 3.7 years, 1,290 women and 4,286 men died. Female sex was associated with a significant risk of death among UNOS status 1A (adjusted hazard ratio [HR]: 1.20; 95% confidence interval [CI]: 1.05 to 1.37, p = 0.01) after adjusting for more than 30 baseline variables. In contrast, female sex was significantly protective for time to death among UNOS status 2 patients (adjusted HR: 0.75; 95% CI: 0.67 to 0.84, p < 0.001). No sex differences were noted among UNOS status 1B patients.ConclusionsThere are sex differences in survival between women and men awaiting heart transplantation, and the current UNOS transplant criteria do not account for this disparity.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Factors Influencing the Rate of Flow Through Continuous-Flow Left
           Ventricular Assist Devices at Rest and With Exercise ∗
    • Authors: Levine BD; Cornwell WK, Drazner MH.
      Abstract: The heart failure (HF) community has witnessed a rapid evolution in mechanical circulatory support over the past decade. Following publication of the pivotal HeartMate II trials, continuous-flow left ventricular assist devices (cfLVADs) with an axial rotor (e.g., HeartMate II) quickly replaced the first-generation, pulsatile devices as both a bridge to transplant and as destination therapy for patients with advanced HF (1,2). The centrifugal-flow LVADs (e.g., HeartWare) have recently been approved as a bridge to transplant and are another alternative for patients with advanced HF (3). Major advancements with these newer cfLVADs include a smaller design and long-term durability compared with the larger, pulsatile LVADs (4). However, questions remain over the effects of long-term exposure to nonpulsatile or minimally pulsatile flow on the human body. Moreover, it is uncertain how these devices respond to changes in loading conditions that occur during exercise to match perfusion with metabolic demand.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Exercise Capacity and Mortality in Patients With Ischemic Left Ventricular
           Dysfunction Randomized to Coronary Artery Bypass Graft Surgery or Medical
           Therapy An Analysis From the STICH Trial (Surgical Treatment for Ischemic
           Heart Failure)
    • Authors: Stewart RH; Szalewska D, She L, et al.
      Abstract: ObjectivesThe objective of this study was to assess the prognostic significance of exercise capacity in patients with ischemic left ventricular (LV) dysfunction eligible for coronary artery bypass graft surgery (CABG).BackgroundPoor exercise capacity is associated with mortality, but it is not known how this influences the benefits and risks of CABG compared with medical therapy.MethodsIn an exploratory analysis, physical activity was assessed by questionnaire and 6-min walk test in 1,212 patients before randomization to CABG (n = 610) or medical management (n = 602) in the STICH (Surgical Treatment for Ischemic Heart Failure) trial. Mortality (n = 462) was compared by treatment allocation during 56 months (interquartile range: 48 to 68 months) of follow-up for subjects able (n = 682) and unable (n = 530) to walk 300 m in 6 min and with less (Physical Ability Score [PAS] >55, n = 749) and more (PAS ≤55, n = 433) limitation by dyspnea or fatigue.ResultsCompared with medical therapy, mortality was lower for patients randomized to CABG who walked ≥300 m (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.59 to 0.99; p = 0.038) and those with a PAS >55 (HR: 0.79; 95% CI: 0.62 to 1.01; p = 0.061). Patients unable to walk 300 m or with a PAS ≤55 had higher mortality during the first 60 days with CABG (HR: 3.24; 95% CI: 1.64 to 6.83; p = 0.002) and no significant benefit from CABG during total follow-up (HR: 0.95; 95% CI: 0.75 to 1.19; p = 0.626; interaction p = 0.167).ConclusionsThese observations suggest that patients with ischemic left ventricular dysfunction and poor exercise capacity have increased early risk and similar 5-year mortality with CABG compared with medical therapy, whereas those with better exercise capacity have improved survival with CABG. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595)
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Coronary Microvascular Dysfunction Is Related to Abnormalities in
           Myocardial Structure and Function in Cardiac Amyloidosis
    • Authors: Dorbala S; Vangala D, Bruyere J, et al.
      Abstract: ObjectivesThe purpose of this study was to test the hypothesis that coronary microvascular function is impaired in subjects with cardiac amyloidosis.BackgroundEffort angina is common in subjects with cardiac amyloidosis, even in the absence of epicardial coronary artery disease (CAD).MethodsThirty-one subjects were prospectively enrolled in this study, including 21 subjects with definite cardiac amyloidosis without epicardial CAD and 10 subjects with hypertensive left ventricular hypertrophy (LVH). All subjects underwent rest and vasodilator stress N-13 ammonia positron emission tomography and 2-dimensional echocardiography. Global left ventricular myocardial blood flow (MBF) was quantified at rest and during peak hyperemia, and coronary flow reserve (CFR) was computed (peak stress MBF/rest MBF) adjusting for rest rate pressure product.ResultsCompared with the LVH group, the amyloid group showed lower rest MBF (0.59 ± 0.15 ml/g/min vs. 0.88 ± 0.23 ml/g/min; p = 0.004), stress MBF (0.85 ± 0.29 ml/g/min vs. 1.85 ± 0.45 ml/g/min; p < 0.0001), and CFR (1.19 ± 0.38 vs. 2.23 ± 0.88; p < 0.0001) and higher minimal coronary vascular resistance (111 ± 40 ml/g/min/mm Hg vs. 70 ± 19 ml/g/min/mm Hg; p = 0.004). Of note, almost all subjects with amyloidosis (>95%) had significantly reduced peak stress MBF (
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Reply “Bendopnea” or “Kamptopnea'”: Some
           Thoughts on Terminology and Mechanisms
    • Authors: Thibodeau JT; Levine BD, Drazner MH.
      Abstract: We greatly appreciate the interest of Dr. Falk in our study (1). When designing our study, it was unclear whether bendopnea was mediated via an increase in ventricular filling pressures or some other process (e.g., abdominal girth). Our study demonstrated that the mechanism of bendopnea was a further increase in filling pressures among those with a baseline increase in such.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Heart Failure: Where the Paths Cross
    • Authors: O'Connor C.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • “Bendopnea” or “Kamptopnea'” Some Thoughts on
           Terminology and Mechanisms
    • Authors: Falk RH.
      Abstract: Thibodeau et al. (1) are to be congratulated on their detailed hemodynamic study of the effects of bending on intracardiac pressures. They demonstrate that dyspnea with bending is associated with a significant positional elevation of right- and left-sided filling pressures. The phenomenon was also seen in subjects without dyspnea, indicating that a physiological change produces symptoms when bending results in excessively high cardiac filling pressures. Although the authors postulate that the mechanism of increased cardiac filling pressure during bending is due to an increased intrathoracic pressure, they do not address the mechanism, nor do they consider the effect of bending on intra-abdominal pressure, an alternative and perhaps more likely mechanism. Indeed, it is disturbing that, in a paper published in an issue of JACC: Heart Failure with a “mini focus” on the physical examination, there is no mention of the presence or absence of hepatomegaly, despite the existence of biventricular heart failure in many subjects and despite a congested liver being a potentially critical factor in dyspnea on bending.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Disease Progression in Pulmonary Arterial Hypertension Refining the
           Phenotype With a Prognostic Biomarker Profile From Collagen ∗
    • Authors: Rame J; Vaidya A.
      Abstract: Pulmonary arterial hypertension (PAH) is a progressive syndrome of right heart failure that encompasses multiple etiologies and risk factors. The presentation, clinical progression, and response to therapeutic intervention are variable across patients, and much interest has been directed in clinical and translational studies to identify the high-risk patient with a poor prognosis.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Circulating Collagen Biomarkers as Indicators of Disease Severity in
           Pulmonary Arterial Hypertension
    • Authors: Safdar Z; Tamez E, Chan W, et al.
      Abstract: ObjectivesThe goal of this study was to determine if biomarkers of collagen metabolism in PAH identify patients with worse disease and higher risk of death.BackgroundThe relationship between circulating markers of collagen metabolism, degree of disease severity, and outcome in pulmonary arterial hypertension (PAH) is unknown.MethodsPatients with stable idiopathic, anorexigen-associated, and hereditary PAH were prospectively enrolled. Levels of the following collagen biomarkers were measured: N-terminal pro-peptide of type III procollagen (PIIINP), C-terminal telopeptide of collagen type I (CITP), matrix metalloproteinase (MMP)-9, and tissue inhibitor of metalloproteinase (TIMP)-1. Patients were divided into mild, moderate, and severe PAH groups. Data were compared between tertiles of each biomarker. Pearson correlation and Spearman rank coefficient analyses were performed. Data on time to death or transplantation were examined by Kaplan-Meier survival curves.ResultsCirculating levels of PIIINP, CITP, MMP-9, and TIMP-1 were higher in the PAH group (n = 68) as compared with age- and sex-matched healthy controls (n = 37) (p < 0.001 for each). PIIINP levels increased with the severity of disease (p = 0.002). PIIINP tertile data indicated that with increasing levels, 6-min walk distance and cardiac index decreased, World Health Organization functional classification worsened, and resting heart rate increased. A significant correlation existed between PIIINP levels and worsening World Health Organization functional classification (rs = 0.320; p < 0.01), and there was a negative correlation between cardiac index and 6-min walk distance (r = −0.304 and r = −0.362, respectively; p < 0.05). PIIINP tertiles showed a trend toward worse outcome in patients with higher tertiles (lung transplant or death) (p = 0.07; log-rank test).ConclusionsMarkers of collagen metabolism were associated with worse disease in patients with PAH.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Heart Failure in Ethnic Minorities Slow and Steady Progress ∗
    • Authors: Piña IL; Ventura HO.
      Abstract: “No Chinese will leave his home to seek his fortune at a distance unless he is in some way driven to do so… No Chinese leaves his home not intending to return. His hope is always to come back rich, to die and be buried where his ancestors are buried.”—A.H. Smith (1)
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Spectrum and Outcome of Primary Cardiomyopathies Diagnosed During Fetal
    • Authors: Weber R; Kantor P, Chitayat D, et al.
      Abstract: ObjectivesThe purpose of this study was to determine the phenotypic presentation, causes, and outcome of fetal cardiomyopathy (CM) and to identify early predictors of outcome.BackgroundAlthough prenatal diagnosis is possible, there is a paucity of information about fetal CM.MethodsThis was a retrospective review of 61 consecutive fetal cases with a diagnosis of CM at a single center between 2000 and 2012.ResultsNonhypertrophic CM (NHCM) was diagnosed in 40 and hypertrophic CM (HCM) in 21 fetuses at 24.7 ± 5.7 gestational weeks. Etiologies included familial (13%), inflammatory (15%), and genetic-metabolic (28%) disorders, whereas 44% were idiopathic. The pregnancy was terminated in 13 of 61 cases (21%). Transplantation-free survival from diagnosis to 1 month and 1 year of life for actively managed patients was better in those with NHCM (n = 31; 58% and 58%, respectively) compared with those with HCM (n = 17; 35% and 18%, respectively; hazard ratio [HR]: 0.44; 95% confidence interval [CI]: 0.12 to 0.72; p = 0.007). Baseline echocardiographic variables associated with mortality in actively managed patients included ventricular septal thickness (HR: 1.21 per z-score increment; 95% CI: 1.07 to 1.36; p = 0.002), cardiothoracic area ratio (HR: 1.06 per percent increment; 95% CI: 1.02 to 1.10; p = 0.006), ≥3 abnormal diastolic Doppler flow indexes (HR: 1.44; 95% CI: 1.07 to 1.95; p = 0.02), gestational age at CM diagnosis (HR: 0.91 per week increment; 95% CI: 0.83 to 0.99; p = 0.03), and, for fetuses in sinus rhythm, a lower cardiovascular profile score (HR: 1.45 per point decrease; 95% CI: 1.16 to 1.79; p = 0.001).ConclusionsFetal CM originates from a broad spectrum of etiologies and is associated with substantial mortality. Early echocardiographic findings appear useful in predicting adverse perinatal outcomes.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Differences in the Clinical Characteristics of Ethnic Minority Groups With
           Heart Failure Managed in Specialized Heart Failure Clinics
    • Authors: Choi D; Nemi E, Fernando C, et al.
      Abstract: ObjectivesThe purpose of our study was to compare the clinical features of Chinese and South Asians, the 2 largest minority populations in Canada, with non-Chinese/non-South Asian (NCH/NSA) patients managed in common social macroenvironments and healthcare systems.BackgroundHeart failure is an increasingly prevalent condition. Although ethnic minorities comprise a growing proportion of the population in Western countries, the clinical profiles of ethnic minorities with heart failure are largely unknown.MethodsWe analyzed records of patients with heart failure managed in 2 specialized clinics in Ontario, Canada. Of the 1,671 patients, 181 (11%) were identified as Chinese and 215 (13%) as South Asian.ResultsOur analyses showed that fewer Chinese patients were found to have a history of myocardial infarction (MI) (30% vs. 52%), 3 occluded/stenosed coronary vessels on angiogram (47% vs. 51%), grade 3 or worse left ventricular dysfunction (22% vs. 42%), and a prescription of angiotensin-converting enzyme inhibitors (42% vs. 63%) compared with their NCH/NSA counterparts. In contrast, South Asian patients more frequently had a past history of an MI (70% vs. 52%), 3 occluded/stenosed coronary vessels on angiogram (68% vs. 51%), and treatment with coronary revascularizations (55% vs. 40%) compared with NCH/NSA patients.ConclusionsOur study demonstrates important differences in comorbid conditions, clinical characteristics, and treatment patterns among Chinese and South Asian patients compared with NCH/NSA patients with heart failure. Awareness of these differences will help to develop differential strategies necessary to prevent and manage heart failure among ethnic minority groups.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
  • Does Low Bone Mineral Density Cause a Broken Heart' ∗
    • Authors: Lyles KW; Colon-Emeric CS.
      Abstract: Osteoporosis, with its attendant fractures, is one of the most common and heart-breaking conditions in our aging society. In the United States, 2 million osteoporotic fractures occur each year, of which some 600,000 are in men (1). These skeletal events cause significant pain, disability, and functional impairment. For patients with a hip fracture, two-thirds must spend time in a rehabilitation or nursing facility. Once home, 50% of these women and men never return to their previous level of ambulation and function (2). Hip and other osteoporotic fractures are morbid events; 15% to 25% of patients with a hip fracture die within 12 months of the fracture (3). Although these devastating consequences of osteoporosis have long been appreciated, new research in this issue of JACC: Heart Failure(4) suggests that osteoporosis may also be literally causing broken hearts.
      PubDate: Fri, 01 Aug 2014 00:00:00 GMT
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