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Contribution of Cardiac Implantable Electronic Devices to Thrombus Formation in Patients With Chronic Thromboembolic Pulmonary Hypertension
Author + information
- Received May 22, 2018
- Revision received August 20, 2018
- Accepted August 20, 2018
- Published online November 19, 2018.
Article Versions
- previous version (September 26, 2018 - 11:00).
- You are viewing the most recent version of this article.
Author Information
- Rohith Nayak, BAa,
- Timothy M. Fernandes, MD, MPHb,
- William R. Auger, MDa,
- G. Victor Pretorius, MBChBc,
- Michael M. Madani, MDc and
- Ulrika M. Birgersdotter-Green, MDd,∗ (ubgreen{at}mail.ucsd.edu)
- aDepartment of Medicine, School of Medicine, University of California, San Diego, La Jolla, California
- bDivision of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, California
- cDepartment of Surgery, University of California, San Diego, La Jolla, California
- dDivision of Cardiovascular Medicine, University of California, San Diego, La Jolla, California
- ↵∗Address for correspondence:
Dr. Ulrika Birgersdotter-Green, Pacemaker and ICD Services, UC San Diego Health, Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of California, San Diego, 9452 Medical Center Drive, MC 7411, Altman Building, 3rd Floor, Room 3E-313, La Jolla, California 92037.
Graphical abstract
Objectives This study aimed to identify the prevalence of cardiac implantable electronic devices (CIEDs) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to describe the associated disease burden.
Background CTEPH is a debilitating disease, now potentially curable with pulmonary thromboendarterectomy (PTE). The contribution of CIEDs to thrombosis in this patient population has not been previously studied.
Methods The charts of 982 CTEPH patients, who underwent PTE between January 1, 2009, and December 31, 2015 at University of California-San Diego (UCSD) Medical Center, were reviewed for pacemakers or implantable cardioverter defibrillators (ICDs) implanted before surgery.
Results Among 982 CTEPH patients who underwent PTE, 14 had pacemakers and 3 had ICDs, giving 17 CIEDs and a prevalence of 1.7%. Of these 17 CIEDs, 6 devices were extracted intraoperatively, and 5 of 6 devices were replaced with epicardial leads. Furthermore, of the 950 patients classified by intraoperative UCSD level, 12 of 17 (70.6%) patients with CIEDs had distal disease versus 241 of 933 (25.8%) patients without CIEDs (p = 0.0002). The prevalence of known venous thromboembolism (VTE) was 50% in CIED patients compared with 78.6% in patients without CIEDs (p = 0.018).
Conclusions At 1.7%, the prevalence of CIEDs in the PTE population was higher than previously reported values, which estimated CIED prevalence between 0.16% and 0.47% in the general population. Moreover, CTEPH patients with CIEDs were more strongly associated with distal disease burden and less likely to have had previous VTE, which suggested that CIEDs may be a nidus for small clots that embolize distally in the pulmonary vasculature.
Pulmonary hypertension, which is characterized by mean arterial pressure ≥25 mm Hg at rest in the pulmonary vasculature, is a progressive and debilitating disease with a number of underlying etiologies (1,2). One cause of pulmonary hypertension is chronic pulmonary thromboembolic disease, which is characterized by recurrent, obstructive clots within the pulmonary vasculature (3). Thrombi within the pulmonary vasculature can occur in the aftermath of an incompletely resorbed pulmonary embolism (PE), and over time, constant obstruction and vascular remodeling within the pulmonary artery can lead to chronic thromboembolic pulmonary hypertension (CTEPH) (4).
Unlike other causes of severe pulmonary hypertension, CTEPH is potentially curable without lung transplantation through a surgical procedure known as pulmonary thromboendarterectomy (PTE). The surgery effectively removes obstructing thrombi from the pulmonary vasculature and significantly reduces disease burden by improving ventilation/perfusion scan (V/Q) mismatch, right heart dysfunction, and tricuspid regurgitation (1,2,5). PTE has achieved remarkable results in decreasing CTEPH disease burden and can deliver a complete cure in >90% of patients (5,6).
One of the central questions about CTEPH is why some patients are more susceptible than others in developing recurrent thromboembolic disease. CTEPH patients are more likely to be coagulopathic than the general population, but it is important to consider other contributing factors as well. We have observed incidental lead thrombi in CTEPH patients with cardiac implantable electronic devices (CIEDs), which suggests that leads may be a nidus for clot formation in these patients. Leads as a potential contributor to thrombus formation in CTEPH patients is a topic that has not been formally studied in the literature. This study aimed to identify the prevalence of CIEDs in patients who underwent PTE at the University of California-San Diego (UCSD) Medical Center and to describe the associated disease burden.
Chart review
The study included 982 patients who underwent PTE between January 1, 2009 and December 31, 2015 at UCSD Medical Center. Each patient's electronic medical record was reviewed for presence of an CIED implanted before surgery. Device type and model, lead indication, and intraoperative changes in lead management, including extraction and replacement, were obtained. Demographic information, including age, sex, body mass index (BMI), functional capacity (according to the World Health Organization), and comorbidities, was collected. Pre-operative and post-operative hemodynamic data were also recorded.
Level of disease
During surgery, the endarterectomy specimens of CTEPH patients were classified by intraoperative UCSD level, depending on what level of pulmonary vasculature was affected. The classification system is as follows. Type 1 refers to a proximal, large vessel clot in the main pulmonary artery. Type 2 refers to chronic fibrotic disease in the main pulmonary artery and clot in the lobar vessels. Type 3 represents a distal clot in the segmental and subsegmental branches. Finally, type 4 disease affects intrinsic small vessels and is often inoperable (5,6). Patients with type 3 or 4 lesions bilaterally are designated as having distal disease; all other patients are classified as having proximal disease. During chart review, each patient's disease level was documented from the PTE operative notes.
Statistical analysis
All statistical analyses were completed using SPSS software version 25.0 (IBM, Armonk, New York). Continuous variables were expressed as mean ± SD; categorical variables were expressed as counts and percentages. Continuous variables were analyzed with the Student's t-test for normally distributed data. Categorical variables were compared with the chi-square test and the Fisher exact test for small sample sizes. A 2-sided p value of <0.05 was used for all analyses.
The study included 17 CTEPH patients with CIEDs (70.6% men; mean age: 58.0 ± 14.4 years) and 965 CTEPH patients without CIEDs (51.2% men; mean age: 52.1 ± 14.7 years). Compared with CTEPH patients without CIEDs, patients with CIEDs had a distribution of World Health Organization functional class that was more severe (p = 0.03). The CIED group had a higher prevalence of coronary artery disease (35.3% vs. 14.4%; p = 0.02) and chronic kidney disease (29.4% vs. 13.3%; p = 0.05), but other comorbidities, such as diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and asthma were similar between the 2 groups. The prevalence of known previous venous thromboembolism (VTE) was 50% in CIED patients compared with 78.6% in patients without CIEDs (p = 0.018). Additional demographic information is shown in Table 1.
Pre-operative and post-operative hemodynamics
As shown in Table 2, CTEPH patients with CIEDs had a pre-operative mean pulmonary artery pressure of 41.8 ± 6.1 mm Hg, a cardiac index of 2.2 ± 0.5 l/min/m2, and a pulmonary vascular resistance of 600.9 ± 243.0 dyn-s/cm5. CTEPH patients without CIEDs had comparable pre-operative hemodynamics (Table 2). CTEPH patients with CIEDs had a left ventricular ejection fraction (LVEF) of 62.9 ± 11.9% compared with an LVEF of 67.4 ± 7.0% in CTEPH patients without CIEDs (p = 0.01).
Post-operatively, CTEPH patients with CIEDs did not significantly differ from those without CIEDs in mean pulmonary artery pressure (25.8 ± 7.4 mm Hg vs. 24.3 ± 7.2 mm Hg; p = 0.42). Final mean pulmonary vascular resistance in the CIED group was 256.9 ± 106.0 dyn-s/cm5 compared with 242.0 ± 122.2 dyn-s/cm5 in patients without CIEDs (p = 0.63). The change in pulmonary vascular resistance between groups following surgery was also not significant (343.9 ± 242.3 dyn-s/cm5 vs. 429.5 ± 328.7 dyn-s/cm5; p = 0.09) (Table 3).
Prevalence of CIEDs in PTE population
Among 982 total CTEPH patients who underwent PTE, 14 had pacemakers and 3 had implantable cardioverter-defibrillator (ICDs), giving a total of 17 CIEDs, for a prevalence of 1.7%. The 14 pacemakers were further categorized as dual chamber (n = 7), single chamber unipolar (n = 1), single chamber bipolar (n = 1), and unknown (n = 5). All 3 of the ICD devices were dual chamber. Indications for CIED placement included sick sinus syndrome (n = 9), symptomatic bradycardia (n = 2), idiopathic cardiomyopathy (n = 2), third-degree atrioventricular block (n = 1), tachycardia-bradycardia syndrome (n = 1), prolonged QT syndrome (n = 1), and junctional rhythm (n = 1). In addition, 2 of the 17 CIED patients had a history of device infections that required device extraction and eventual replacement.
Intraoperative lead management and level of disease
Among the 17 CTEPH patients with CIEDs, 6 patients (35.3%) had their devices extracted intraoperatively, and 5 of these 6 patients (83.3%) had their devices replaced with epicardial leads (Table 4). One patient had a new dual-chamber permanent pacemaker placed during surgery. Furthermore, patients with CIEDs had more distal chronic thromboembolic disease than those without devices, defined as UCSD level 3 or 4. Of the 950 patients classified by intraoperative UCSD level, 12 of 17 (70.6%) patients with CIEDs had distal disease versus 241 of 933 (25.8%) patients without CIEDs (p = 0.0002) (Table 5).
In this retrospective analysis of patients referred for PTE, we found a CIED prevalence of 1.7% among patients with CTEPH; furthermore, CIEDs were associated with an increased prevalence of distal chronic thromboembolic disease. At 1.7%, the CIED prevalence in the UCSD PTE population was much higher than all previously reported national estimates of CIEDs in the general population (7–13). Furthermore, the incidence of known VTE in the CIED population who were diagnosed with CTEPH was significantly lower than the CTEPH population at-large. This suggested that CIEDs might give rise to small thrombi on the wires, which might cause silent pulmonary emboli (Figures 1 and 2). Ultimately, these silent pulmonary emboli could contribute to the development of CTEPH in susceptible individuals. Because of the lack of a CTEPH negative reference group in this study, the higher prevalence of CIEDs observed in this CTEPH cohort, compared with other registries, might also reflect differences in baseline comorbid conditions among populations.
The role of blood-contacting medical devices (e.g., stents, vascular grafts, and heart valves in thrombus formation) has been well documented in the biomaterials literature. It is likely that CIEDs, like other artificial surfaces in the blood stream, promote clotting through a complex cascade of protein adsorption, cell adhesion, thrombin generation, and complement activation (14).
A number of previous studies specifically substantiated the phenomenon of lead thrombogenicity. In a 7-year prospective study, which included both children and adults, Bar-Cohen et al. (15) found partial and total venous obstruction in patients with CIEDs, regardless of age, body surface area change, lead type, age at implantation, and number of leads placed. A recent population-based cohort study by Pederson et al. (16) found a 3-month VTE risk of 0.3% and 5-year VTE risk of 1.9% after ICD implantation. Moreover, multiple studies examined intracardiac lead thrombi. In a retrospective cohort study of patients with previous pacemakers or ICD implantation who underwent intracardiac echocardiography for ablation of atrial fibrillation, atrial flutter, or ventricular tachycardia, Supple et al. (17) found 26 of 86 (30%) patients with intracardiac lead thrombi. The post-mortem analysis by Novak et al. (18) in deceased patients with pacemakers and ICD leads demonstrated a similar rate (28%) of intracardiac lead thrombi and showed that a number of patients had simultaneous venous and intracardiac thrombi. There were no studies to date to compare the potential thrombogenicity of specific lead materials (e.g., silicone and polyurethane); the sample size of CIEDs in our study was too small to draw conclusions regarding the thrombogenicity of these materials.
Previous studies mentioned that CIEDs might be a potential risk factor for distal disease burden in CTEPH patients, but none of these studies formally investigated or quantified this hypothesis (5). Our analysis demonstrated that CTEPH patients with CIEDs were more strongly associated with distal disease, which suggested that leads might be a nidus for the development of small clots that embolize to the segmental and subsegmental vessels of the pulmonary vasculature. Thrombi within these more distal vessels are more difficult to remove during surgery and might even make the disease inoperable at some institutions (19). However, at UCSD, despite the higher risk of distal disease, CTEPH patients with CIEDs had comparable post-operative hemodynamics and outcomes as those in CTEPH patients without devices. This implied that CTEPH patients with CIEDs are good candidates for PTE, and that surgeons should continue to operate on these patients while considering the removal of CIEDs from the blood stream to decrease the risk of recurrent disease.
Study limitations
Although we included a large number of CTEPH patients, our study was a retrospective analysis from a single medical center. Moreover, the absence of a negative reference group prevented us from drawing definitive conclusions about causality.
CIEDs are more prevalent in the CTEPH population than the general population and are associated with more distal disease. Electrophysiologists should consider CTEPH as a potential cause of dyspnea in patients with long-standing devices and those with known clots on wires. These patients can be screened for CTEPH with a VQ scan; those with abnormal perfusion should be referred for thorough evaluation of CTEPH and determination of surgical candidacy by centers that offer PTE surgery.
COMPETENCY IN MEDICAL KNOWLEDGE 1: CTEPH may be a potential late complication of CIED placement in susceptible patients.
COMPETENCY IN MEDICAL KNOWLEDGE 2: CTEPH patients with CIEDs are associated with more distal disease burden; however, they remain good candidates for PTE.
TRANSLATIONAL OUTLOOK 1: Electrophysiologists should consider CTEPH as a potential cause of dyspnea in patients with CIEDs and initiate further clinical workup.
Dr. Fernandes has been a consultant for MSD/Bayer; and has been a speaker for Bayer Pharmaceuticals. Dr. Auger has been a consultant for MSD/Bayer; and has received grant support from Bayer. Dr. Madani has been consultant for MSD/Bayer, Johnson & Johnson, and Wexler Surgical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- body mass index
- cardiac implantable electronic device
- chronic thromboembolic pulmonary hypertension
- implantable cardioverter-defibrillator
- left ventricular ejection fraction
- pulmonary embolism
- pulmonary thromboendarterectomy
- University of California-San Diego
- venous thromboembolism
- Received May 22, 2018.
- Revision received August 20, 2018.
- Accepted August 20, 2018.
- 2018 American College of Cardiology Foundation
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The Tag Grid – A virtual world, built on dreams - Virtual adult worlds
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By Gardakinos - 14:03
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Second Life is an internet-based virtual world launched June 23, and developed by Linden Massively Multiplayer Online Games (MMOGs) and non-game virtual worlds for less money and in less time than ever before. Adults only.
By Garisar - 06:20
Chathouse 3D is an adult-oriented virtual world – a multiplayer online virtual sex game environment – that makes use of the Oculus Rift's VR.

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Do you know Smoothie King Feedback Survey on SmoothieKingFeedback.com? Smoothies are relaxing, fulfilling, and full of nutrition. On a sunny afternoon, there is nothing relaxing like a cold cup of the drink down your throat. Many doctors and nutritionists always recommend people to have freshly made smoothies. So, where do you get one?
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Smoothie King Feedback Survey Summary on SmoothieKingFeedback.com
|Purchase required
|Age limit
|18 +
|Survey site
|Entry method
|Entry limit
|1 per household every 15 days
About Smoothie King Feedback Survey
Since Smoothie King is all about customers, they treat the customer as king. They understand that for the business to grow and expand, they have to keep customers happy and coming for more. So, how do they know that the customers are happy with what they have and what they need to change?
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Smoothie king wants you to voice your opinion. Tell them how happy or unhappy you are about their food and services by taking the survey. It the receipt you get when you buy, you can give your feedback and get a coupon to use during your next visit.
About Smoothie King
What started as an unfortunate incident turned out to be a business venture for Steve Kuhnau. When he was a teenager working as a soda jerker, he fell sick and went to the hospital. The doctors diagnosed him with hyperglycemia, a condition that makes you non-tolerant to lactose in milk.
While under medication, doctors gave advice on how to make food and smoothies full of nutrients while avoiding dairy products and that is how the idea came. He started the business in order to create a place where people with a condition as he can come and have a refreshing drink without worrying about getting sick.
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Wiki: Smoothie King.
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How to Take Smoothie King Feedback Survey
Do you know how to give your Smoothie King feedback? After making sure you have what you need for the survey, you need to take the following step of going ahead and giving your feedback, if it is your first time, read the following guideline to give your feedback:
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Having a health condition or on a diet does not mean you cannot enjoy a freshly made smoothie. That is what Smoothie King assures you. That is by having fresh smoothies of different flavors that are full of nutrients to enjoy every time you crave for a dairy-free smoothie. Tell them your experience by giving your feedback at www.SmoothieKingFeedback.com and get a $1 coupon code.


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Speaking of the group of people you connect with in prison, Stone also said, "You're locked away, you search for a family, you create a family, you find a mother [nods to Kate Mulgrew, who plays mother-like character, Red], you need that." Mulgrew added, with a mischievous grin, "The mother doesn't have a lot of sex."
Alongside the lesbian love affair between Prepon and Schilling's characters, the series also features a transgender character in Sophia, played by transgender actress Laverne Cox, who said you just need to listen to the audience to know what they want to see. "So many networks are just terrified to take any kind of risk especially because of wonderful places like Netflix where people can go and watch TV differently," she said. "Being at a place like Netflix is like 'Let's try it! This is cool!' It's a crazy thing in this business but listen to the people, listen to what the folks want."
And while Cox talked about the show starting a conversation for the trans community, Lea DeLaria, who plays Big Boo on the series, said OITNB has done the same for the butch community. "I can't believe what's happened for me in my life," the actress/comedian explained. "I've been this out person for a long time but usually when a 16-year old boy walks up to me on the street it's to spit in my face and call me 'dyke.' Now, it's to hug me and tell me how much he loves Orange Is The New Black."
DeLaria added that, to this date, she's also signed 44 screwdrivers based on the actions of her character in the show. (And, yes, she did question why people are walking around carrying screwdrivers!).
Noting that the majority of the panelists were women, the question arose about the diversity in the cast and Schilling said, ""Every time I hear this questions asked, and it's come up more and more, it's because of you. You decided to write this," the actress said, gesturing to Kohan. "All of this stuff was in your brain at one point, which is pretty remarkable. To bring a book to an audience is pretty wild."
That said, of the diversity issue and the question still coming up, Kohan, who is not gay but is the sister of television producer David Kohan (Will & Grace), asked, "Why is this such an anomaly? These are great stories and great characters and great women…?"
Prepon commended Netflix for being wise enough to see the opportunity for bringing something different to a television series. "People were scared to go there and do the things that we've done on the show," she said, "and it's awesome and from the audience response we see now that you guys are ready for this. And I think some people are scared to go there but we're proving, no, people want this type of show."
Danielle Brooks, who plays Tasha "Taystee" Jefferson, shared that she thinks the show has connected with the audience because it reflects back on them. "It's also about telling honest, truthful stories," she said. "There are women out there who are like Taystee and that, to me, is telling a true story and giving voice to those who do not have a voice and I think that's what we're doing.
The second season of Orange is the New Black returns June 6 on Netflix.


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Beijing versus Shanghai: a simple yet difficult comparison
My mom, Clare Hamilton, recently visited Shanghai for the third time, and as usual we used her short visit to check out another part of the country for a few days. Last time she really wanted to check out Xi'an's terracotta warriors, and this time we went to Beijing to visit all the usual sites, plus a part of the Great Wall.
We got on the gaotie, or high-speed train, at Shanghai Railway Station and sank back into our seats for the quick trip, and that's when she threw me a hardball: "How are Shanghai and Beijing different, Andy?" I'd never really pondered specifically the differences and similarities between Beijing and Shanghai because I'd always thought it was obvious.
For many foreigners with not much background knowledge on China, Beijing and Shanghai are probably the only two cities they can name on the Chinese mainland. They know both are huge, but that's about it.
Beijing feels more raw and real, and Shanghai feels more polished and international.Clare Hamilton
When I thought a little deeper about the differences, all I could come up with in the beginning were feelings. "Shanghai feels more 'big city' and Beijing feels more 'Chinese,'" was my first attempt.
It was met with a blank stare, and I knew I had failed. "More Chinese?"
I knew I had to do better, and after a bit more thinking I came up with a few more answers.
Politics and Beijing
Politics is never far from discussions about Beijing, for obvious reasons: It's the capital of China and the seat of the central government. That alone sets it apart in tone from Shanghai. Beijing features all of the institutions of government, including the Great Hall of the People, which connects with Tian'anmen Square, literally at the heart of the city. A visit to Beijing isn't complete without entering the square and soaking up the patriotic atmosphere. You can also check out the body of Chairman Mao, although it's definitely a fleeting look as people are shuffled past by the hundreds in mere seconds.
Imperial China
Beijing has been the capital of China, and was the home of emperors, for hundreds of years, giving the city an air of historical significance. Across the road from Tian'anmen Square is the Forbidden City. Construction started in 1406, and nearly 1,000 of the complex's original buildings still survive to this day.
The Great Wall, or part of it
Adding to Beijing's historical significance is the fact that the city is not far from a famous stretch of perhaps China's most iconic creation: the Great Wall. Although there are parts of the wall that survive all over the country, many tourists decide to check out the section in Beijing because it's easy to get to and has great access by way of gondola. Be prepared for huge crowds and photos filled with strangers.
Dry, cold winters
Beijing is also known for its dry, cold winters. Unlike Shanghai, winter in the north can leave your skin dry and your lips chapped. The temperature often sits below zero, and snow isn't uncommon. For me, winter in Beijing is iconic, and seeing steam belching out of noodle shops on a sunny winter's day really warms my heart for some reason. If you're visiting the city in winter, don't forget your chapstick!
After we arrived back in Shanghai, I was pleased when mom said she knew what I meant earlier about the "feeling" thing. While she loves both cities, she agreed they very much have a different feeling or vibe about them. "Beijing feels more raw and real," she said while obviously thinking deeply. "And Shanghai feels more polished and international." I couldn't have put it better myself!


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Lukas Moritz Wegscheider is a electronic music composer, instrument builder and photographer from Tyrol, Austria. He is currently studying at the University of Performing Arts in Graz, Austria. Before his study, he made his apprenticeship in musical instrument building. As an artist, be it audio or visual, he is interested in nostalgia and melancholy from an impersonal point of view, by leaving a aesthetically "blurred" impression. With his tape loop performances he wants to focus on room-atmosphere, collective mood, nostalgia, melancholy and the hauntological phenomenon. The endless repetitions, sharpen the acoustic perception and allow the discovery of new sound events. This image gets distorted and blurred until the focus is placed on the distortion and the blurredness itself. Influences of Minimal Music and Ambient, combined with the atmosphere of the hauntology theory and lo-fi aesthetics.
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A's Khris Davis has his usual blast in Texas, gives Oakland a comeback win
ARLINGTON, Texas — Seldom is baseball predictable, but Khris Davis homering at Texas is becoming a near ritual, and Friday, his blast gave the A's their fourth win in a row.
Globe Life Park is Davis' personal playground. On Friday, he saved his biggest swing for a particularly dramatic moment. With the score tied in the eighth, the A's DH parked the first pitch from Chris Martin out to center, the deciding blow in Oakland's 8-6 comeback victory over the Rangers.
"Big shocking event — Khris hit a go-ahead home run here," A's manager Bob Melvin said, deadpan. "We've seen him do it a few times. But to continue to do it? It's a lot to ask. When he's swinging like he is, he's capable of doing it."
Davis has hit five homers in the past three games and leads the majors with 10. Friday's heroics seemed pretty much preordained: He entered the night on a tear, going 7-for-19 with four homers at Baltimore. Last year, he hit .297 with 10 homers and 26 RBIs in 19 games against the Rangers, with seven homers and 19 RBIs coming in Texas. His 16 homers at Globe Life Park are tied with Albert Pujols for the most by an active opposing player.
"It's just like a matter of time when he comes up, especially with as hot as he's been, hitting them out to right, hitting them out to left," A's catcher Josh Phegley said. "In this park, he's right at home. We fully expect that to happen."
Last year's 97-win team recorded 42 come-from-behind victories, and Friday's game had that vibe for Oakland's players. "I thought we battled back well," Davis said after his team overcame a 6-1 deficit. "I don't think we thought we were out of that game at all, even though we got down early. There wasn't a sense of panic and before you know it, we were ahead."
"It's an attitude with this team," Phegley said. "The confidence we have to hit our way back into games is there, and we know it.
Davis and the rest of the Oakland lineup did some heavy lifting to wipe out a six-run mess by starter Mike Fiers, the second start in a row he's allowed that many. At least this time, he got deeper into the game. His previous outing, at Houston, Fiers lasted just 1 ⅔ innings. Friday, he made it through five innings, but needed 100 pitches to do so.
In three starts and 9 ⅔ innings pitched away from the Coliseum, including Opening Night in Japan, Fiers has allowed 18 hits, seven walks and 17 earned runs.
"I haven't been leading this team, I haven't been stepping up and making pitches and I'm getting burned for it," Fiers said. "Luckily, we're swinging the bats well and they keep picking me up, but there's got to be a time I turn this around and I will, but right now it sucks, pitching like that and always putting us in a hole."
Fiers gave up two runs in the first but settled down until giving up a solo homer to Asdrubal Cabrera in the fourth. In the fifth, Delino DeShields singled and Shin-Soo Choo reached on a bunt. After Logan Forsythe hit into a fielder's choice, Elvis Andrus delivered a three-run homer to right.
Feeling at home
Cities in which Khris Davis has hit the most home runs:
Arlington, Texas
Source: baseball-reference.com
Oakland made little headway early against lefty Drew Smyly, though Stephen Piscotty provided the first hit with two outs in the second and Jurickson Profar, making his first appearance against his former team, drove in Piscotty with a double.
Finally, down by five, the A's really got going in the sixth.
Phegley started things off with a base hit, and Smyly walked Marcus Semien and Mark Canha before departing, then Matt Chapman whacked a two-run single off former A's reliever Jesse Chavez. Davis' grounder to third sent in another run, but Chapman tried to advance to third on the throw to the plate and was out. Chad Pinder hit into a force, then scored on a double by Piscotty, cutting Texas' lead to one.
Ramón Laureano tied it up the next inning off another ex-Oakland reliever, Shawn Kelley, hitting a blast into the Texas bullpen in right center, his third home run of the season. Phegley added an RBI single in the ninth; he's batting .414 during his career-high eight-game hitting streak.
The A's have hit multiple homers in six consecutive games, tying the franchise record, done five times previously including Sept 18-23, 2013.
With Fiers' stumble, the A's bullpen took center stage the final four innings. Yusmeiro Petit worked a 1-2-3 sixth, Lou Trivino handled 1 ⅓ innings and left after a double by Nomar Mazara in the eighth, and lefty Ryan Buchter struck out Joey Gallo on a 95 mph fastball. Blake Treinen then entered for a four-out save, his fifth save in six chances.
In Baltimore, Buchter got a chance to work a full inning and get some kinks out. Manager Bob Melvin noted the next day that it could pay dividends for Buchter, the only left-hander in the bullpen.
"It's just been a command issue with him, it hasn't been stuff," Melvin said. "He's been getting behind, first guy walks again, now you need some reps to get through something like that. For situational guys, sometimes that's not an option and when you're struggling with command, it's tough to get through that because you're not out there long enough to do that. It was good for him to get a full inning."
Susan Slusser is a San Francisco Chronicle staff writer. Email: firstname.lastname@example.com Twitter: @susanslusser


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Kaya elders from the Coast region will conduct 'special prayers' within their 9 sub-tribes within Kwale and Kilifi Counties to seek God's divine in taming Coronavirus in the country.
The announcement comes Kenyans prepares for the national prayer day on March 21st. 2020 called by the head of state president Uhuru Kenyatta.
The national prayers will be conducted at the State house in Nairobi.
The sacred forest prayers according to the Kaya elders will complement the national prayers in seeking 'gods' intervention against the scourge of the dreadful COVID-19.
The disease originated in the Chinese City of Wuhan in late December last year.
8,648 deaths
The infection of the novel COVID-19, according to the World Health Organization, is more than 207,000 with at least 8,648 deaths in at least 166 countries globally.
Mijikenda Kaya Elders Association (MKEA) Chairperson Mwinyi Mwalimu says their prayers will revoke the traditional spirits' intervention to protect Kenyans from the spreading infectious disease.
"We follow strict procedures for prayers that our forefathers directed us to conduct whenever we faced crisis just like whats the world is currently facing," disclosed the Chairman.
Meanwhile, MKEA Coordinator, Johnson Ndokolani, noted that the traditional prayers will be conducted not only in the Kaya's but also in other sacred places from different communities within the Coastal region.
Nothing but…
"Although Coronavirus is disastrous, but there is nothing bigger than prayers," he said.
The elders were speaking after making a short special prayer at the Uhuru Gardens in Mombasa County on Thursday.
They called on Kenyans to observe general personal hygiene to prevent themselves from the virus.
"Our people must observe strict guidelines on their personal hygiene as specified by the Ministry of health as we indulge our forefathers in special prayers to intervene," reiterated Ndokolani.
Another elder, Juma Mnyeto, urged the government to ensure there is adequate provision of clean water to encourage had washing practice among locals.
"If there is no running water in our taps, then it will be a tough call asking people to constantly wash their hands when the commodity is highly scarce," he said.


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Tag Archives: Sport
An Ode To Bruce Lee – Placing Him In His Rightful Place
It's about time Bruce Lee be given his proper place in the history of modern mixed martial arts. Bruce Lee, pound for pound, was arguably the greatest fighter of our time. He is certainly the most popular. Fourty-one years after … Continue reading
Posted in Culture, Health and Fitness, Martial Arts, Philosophy, Religion, Spirituality Tagged Bruce Lee, Confucianism, Jiu-Jitsu, legend, life, Martial Arts, Mixed Martial Arts, MMA, philosophy, Sport, The Way Leave a comment
Life Isn't A Journey, It's An Obstacle Course
The Olympic Games have a reputation of representing the purest, highest repository of human athletic ability. Yet amid the pomp, there always seem to be a handful of events derided as "not Olympic"—whether it's an obscure hybrid like ski cross; … Continue reading
Posted in Uncategorized Tagged America, Ancient, ancient egypt, Athletic, British Empire, education, fitness, Greek, health, humanity, life, Obstacle course, Olympic Games, Olympics, Roman Empire, Rome, SDT Theory, Spartan Race, Sport, United States, World War II 4 Comments
A Race To The Flop
Let's ask ourselves a question shall we? If this is a Race to the Top are we (the United States of America) in any shape to win? Sports Mirrors Life; It's NOT just a Game. In Sports as in Life … Continue reading
Posted in Uncategorized Tagged children, climate, Global, health, life, live, love, Obama, Olympics, one love, philosophy, Politics, presidential campaign, Race to the Top, society, Sport, Sports, United States of America, universal, USA, wealth, Wellbeing, women, youtube 2 Comments


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It's really cool to see a brand new industry bloom in front of our eyes. Watching the vape industry and businesses like KMG Imports vaping supplies grow so rapidly over the last few years has been fascinating. With more and more people using vapes to quit smoking, the industry has thrived and now vape companies are starting to incorporate marijuana products into the industry. Not only do we have producers growing countless strains of cannabis with a landscape of unique stores selling the product, companies infusing marijuana greatness into yummy looking treats and marijuana tour guides; but also we have companies like Fez which makes an unique dry herb vaporizer, just so that you can be a little bit more spoiled.
For those of you who are not familiar with dry herb vaporizers, in short, it is a device that allows you to "vape" (not smoke) cannabis in flower form. However, according to CEO Samantha Webster, the Fez dry herb vaporizer worked just fine using flower rolled in oil.
First impressions of the Fez Vaporizer: Size, Weight and Style
First impressions are a big deal, so we're going to start off this Fez vaporizer review with just that. For those who say size doesn't matter, in this case, size does matter. Especially when it refers to a portable vaporizer. If I am going to walk around around, or be mobile, I don't want to carry around a clunky device in my pocket that brands itself as portable. One of my biggest pet peeves in this industry is the clunkiness of something that is considered portable. There are plenty of places like Devine Distribution Wholesale that sell portable vaporizers similar to this one, so it's worth bearing this in mind when considering the type you want.
The Fez dry herb vaporizer is just a hair over six inches in length and just a hair over 1 inch in width,at its' widest point. It fits nicely and comfortably in my hands, and that's without the biggest hands in this world. The weight of the vaporizer is good as well. Just enough to really feel what I'm holding, but not too much where it starts to become noticeable.
In addition to the size and weight, the look of the Fez Vaporizer caught my attention. It is sleek, clean, minimal and stylish. The Fez shield like logo, accents nicely on a 'soft to the touch' surface. According to the website, the Fez herbal vaporizer is available in 3 colors: white, black, and red.
Vaporizer Features
So, what makes Fez stand out? Why would you purchase this vaporizer compared to any other dry herbal vaporizer?
One of the first things that was brought to my attention is the $139 price point According to Webster, there are two general markets of portable dry herb vaporizers. Vaporizers that are cheap with prices that reflect this notion ($40-100), and quality vaporizers that are expensive ($200-350). Webster wanted to bridge the gap by creating high quality dry herb vaporizer with an affordable price tag. The Fez Vaporizer is currently available online only. This is not by accident as it helps to keep the price low.
So what kind of bang do you get for your buck? According to the website, you get a weed vaporizer that allows you to vape cannabis, a 4,000 mvh lithium ion battery that is capable of 2,000 puffs per charge, heats up in less than 60 seconds, 3 temperature settings that allows you to customize your vape session depending on your strains and preferences and a micro USB charger. The Fez vape also comes with a cleaning kit to keep your vaping device tip-top shape.
The Test
I tested the Fez vaporizer over a period of 3 days. To load your favorite herb, you simply turn the mouth-piece clockwise just a bit, to release. Once you have inserted your favorite strain, re-insert the mouth piece by twisting counter-clockwise.
Press and hold the power on button for about a second until the red light turns on. The website and instruction manual states that it takes two seconds but really it's just a second. In less than a minute, the indicator light turns green and you are ready to vape. I should note that the Fez dry herb vaporizer comes with a well designed, easy to use 'User Guide.' If you have never used a vaporizer before, in my opinion, this guide will make it one of the easiest experiences you will have.
The draw from the Fez dry herb vaporizer is legit. It packs a nice smooth punch for its' size. It's easy to inhale, and control the amount of vapor that is inhaled. There is more than enough time to get a good vape or two, before the vaporizer needs to reheat and catch up, which allows you time to catch up as well.
The only real drawback I have is that I wished their was more time before the green light switches off, and a brief waiting period happens before the vaporizer is ready to go again. Oh, and I purchased the white one. Now I think about it, I probably would have liked the black better. And the red one actually looks cool. It's different.
Fez Vaporizer Review Conclusion
Overall, I was very impressed with the Fez dry herb vaporizer. From the portability aspect, to the performance. When you factor in the price point, it really becomes a must buy. Especially, if you are looking for a portable vaporizer that packs a punch. You can purchase the Fez vaporizer directly from there website here.
I hope this review encourages more people to vape, especially since it's much more beneficial for lung health than smoking marijuana. Additionally, those who are just smoking for the advantages of CBD have the ability to enjoy the assets without the psychoactive impact. You can find vaping products for CBD at https://cannaunion.com/product-category/cbd-vaping/, including some fun flavours that you won't get from smoking!
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Disclaimer: Fez is an advertiser on HAS. Oh, but we still dig their product.


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Liverpool manager Jurgen Klopp, speaking to Match of the Day: "All the goals were incredible, outstanding. Wonderful goals, sensational passes, super pieces of football. I loved it a lot!
"We needed fresh legs and I had to show my respect to the boys in the squad, that's all. They proved it. It is much more fun making changes, all of the boys are ready to deliver performances like this.
"It was a massive moment in my first season when Divock Origi got injured in the derby. It changed his career for a bit."
Everton boss Marco Silva, speaking to Match of the Day: "We cannot concede goals in the way we conceded. We knew everything about them before the match and how they like to play whether with Origi, Salah or Firmino, we know how they would play. There was a lot of mistakes.
"I am not the right person to answer about the situation, this question is for different people. We are making some mistakes which put us under big, big pressure. The type of mistakes we are making is because the players are playing under big pressure because of the position in the table."


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Looking up, I knew this was a moment to behold. Across the living room from me sat Jim Forest, laughing among friends while in
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Today I set out walking to walk. Visiting a new city fills me with childlike wonder and awe—each nook a new treasure to behold, every
Notes on Silence… is here!
Many of you know I've been working on co-authoring a book with Patrick Shen. We lovingly titled the work Notes on Silence based on our extensive deep-dive
Encounters with Silence – Thomas Merton's Hermitage
To go seeking for something which cannot be sought. To go on looking for something which cannot be found. To attempt to do something which cannot be done.
The Uncertainty of Silence
(This will be among the many essays featured in the forthcoming book Notes on Silence that I'm co-authoring with Patrick Shen which can be purchased
The Encountering Silence Podcast is Here!
Many of you know I've begun recording a podcast with my dear friends, fellow writers and thinkers, Carl McColman and Kevin M. Johnson. They've focused on


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The Ashcombe wooden bench is a solid garden bench, made to withstand all weathers, and built to last. A simple design to compliment all gardens and outdoor spaces.
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Hilton Strathclyde4
Phoenix Cres.Strathclyde Bus. Park, Bellshill, ML4 3JQ
Phoenix Cres.Strathclyde Bus. Park, Bellshill, ML4 3JQ
I paid £40 more than the other guests as they paid £80 and I paid £120 and that was £40 of a...
Amanda Good
Set between bustling cities of Glasgow and Edinburgh, the Hilton Strathclyde hotel boasts one of Scotland's largest hotel leisure facilities. Just 45 minutes from Edinburgh Airport, and 30 minutes from Glasgow Airport, the hotel boasts six meeting rooms for 2-300 delegates, a business center and wireless internet access in public areas. Dine at your leisure in The Space, with light refreshments, snacks and dishes served all day.
Enjoy free wireless internet access in this relaxed and contemporary setting and sit back on a comfortable armchair with a coffee. All Hilton Strathclyde hotel guest rooms offer on-demand movies, work desk and high-speed internet access. Upgrade to a deluxe room for extra space, seating area, fluffy bathrobes, luxury toiletries, bottle of wine and chocolates. Smoking rooms are available upon request but not guaranteed. Maintain your healthy lifestyle and swim laps in the pool, take a fitness class or work out in the large gym at the Livingwell health club. Unwind after a long day with the various saunas and Jacuzzis or treat yourself to some pampering in one of our five treatment rooms, spray tan facility, nail bar and hairdresser. Both Edinburgh and Glasgow offer vibrant nightlife, culture and shopping. If you are feeling lucky and fancy a flutter, head to Hamilton Race Course. A trip to Amazonia, Scotland's largest indoor tropical rainforest is the perfect family day out. With stunning scenery and Strathclyde attractions like the Drumpellier, Chatelherault and Strathclyde Country Parks, there's something for everyone near the Hilton Strathclyde hotel.
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Our reviews are from genuine LateRooms.com customers. We verify that the customer has stayed before leaving a review.
77% would recommend it to a friend
Customer service
Food quality
Room quality
Have stayed here often and it is like coming home. Well trained staff, welcoming and friendly. Nothing too much trouble and the rooms are comfortable and clean.
Good stay apart from 6am guests leaving the hotel
The accommodation was fine as was the service. Only problem was that it was very, very, hot. Turned the heating off and it was still warm enough to bake a cake. Left with a choice of roasting or opening the window and being deafened by traffic. As there was nowhere else to eat nearby we visited the restaurant. The menu was limited, mainly consisting of 'fast food'. My Cajun chicken was simply a griddled chicken breast, that was no more Cajun than me!My wife's meal was the chefs special consisting of Turkey breast (OK), four or five Brussels and a watery gravy. The potatoes were of the 'smash' dried type and tasted disgusting. I have had considerably better food at motorway service stations and for a lot less money. Very poor effort.
This is the first time I've stayed at this hotel, but I've stayed in this areas many times before, and compared to the competition this hotel is very good value for money. My room looked slightly dated but was clean and spacious. The breakfast was excellent, the staff were very attentive, and the leisure facilities were an added bonus. I would definitely stay again.
We went to Hilton for an overnight for my birthday, it was an absolute treat, we stayed in a duluxe room, it was huge and we got a great deal with laterooms on the price. The breakfast was great too, a very large selection of foods and drinks, and Haggis, my favourite, i would highly reccommend, we hope to go back.
Room was OK but specifically for disabled visitor so sink low, red call cords, not much storage room as areas needed to be easily accessible. No full length wardrobe and difficulty in standing straight in shower because of support handles. Would have been OK but loo handle kept clunking against cistern top. Got the knack in the end. Apart from that room good. Well kept everyday.
Lovely hotel with friendly helpful staff.The hotel is located 30 minutes from Glasgow so car is a must. However if you book this as Hilton Getaway it is worth the extra travel. Close to Bothwell and Hamilton lots to see and do.Recommend this hotel.
Modern, clean, welcoming hotel. Recommended. Only downside the archaic notion of charging an extortionate amount for wifi. Enter the 21st Century Hilton
The hotel's position was perfect, close enough to the motorway to get around but far enough that we were not bothered by the traffic noise. Arrived late and the front desk staff were very friendly and very accomodating. The hotl lobby and resturant was cool and sophisticated, unfirtunatly although adequate this was not continued in our room which was a little dated. Very very clean, the room was perfect for our needs but could be brought a little more up to date. The gym and swimming facilities were great although it was obvious that the members of the pool were a little upset by the hotel users as we and a few other people felt we were intruding on thier time (the staff in this area where lovely) overall it was a lovely stay, food was first class!! Kids loved it and we are returning again as the hospitality was first class! Thankyou!


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FFXIV: Shadowbringers Guide: What's Next After The Main Story?
The world is saved; what now?
The world is saved; what now?
You'll no doubt have encountered Titania and Innocence, bosses that require 8-man parties to beat.
Though tense in their own right, your first run-in with these beasts will surely be through the main story, meaning that the regular trials aren't too punishing on mistakes.
If you think you're up for a challenge, you can find the Wandering Ministrel a little south to the entrance of the Crystarium. Speak to him for a brief while and you'll automatically unlock the Extreme difficulties for Titania and Innocence.
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The Bakerian Lecture. On Some Total Solar Eclipse of July 18th, 1860, observed at Rivabellosa, near Miranda de Ebro, in Spain. [Received January 30, Read April 10, 1862] extracted from Philosophical Transactions of the Royal Society of London for the Year 1862, 152, Part I, Pp. 333-416
London: Taylor and Francis, 1862. 1st Edition. FIRST EDITION COMPLETE EXTRACT FROM THE PHILOSOPHICAL TRANSACTIONS (WITH PLATES) OF DE LA RUE'S BAKERIAN LECTURE PRESENTING HIS GROUNDBREAKING ASTRONOMICAL PHOTOGRAPHY OF THE SOLAR ECLIPSE OF 1860. Included are thirteen de la Rue's plates, among them are some of the most famous images of the Sun ever rendered. de la Rue's efforts constituted "the first systematic application of photography to a solar eclipse" (Bray, Plasma Loops, 2). The photographs he produced "were the first to definitively demonstrate that the corona seen around the moon during a solar eclipse is a phenomenon associated with the sun rather than the moon" (Davidson, Warren de la Rue, 2). There had been much scientific debate as to the nature and origin of the red flames visible at the edges of the moon during an eclipse. De La Rue's photographs firmly established the exclusively solar character of the red flames, now known as prominences, and de la Rue is credited with their discovery.
Warren de la Rue was a British chemist and astronomer whose efforts "helped make photography one of astronomy's greatest tools" (Stanford Solar Center). de la Rue adapted wet plate photography to lunar photography, pioneering "the application of photography to the study of the Moon and Sun [and] in the process demonstrating the value of an equatorially mounted, clock-driven reflecting telescope as a camera, techniques that greatly accelerated the evolution of the new science of astrophysics" (Biographical Encyclopedia of Astronomers, 284).
In the mid-19th century, John Herschel spoke openly about the importance of a daily photographic record of sunspots. In 1854 and at Herschel's urging, the Royal Society granted support to de la Rue to invent a telescope specifically designed for photographing the Sun. de la Rue did just that. His invention, the photoheliograph, was the first astronomical instrument constructed for the photography of celestial objects [and it is described in detail in this paper]. Known as the Kew Photoheliograph, de la Rue's instrument included an achromatic objective, a clockwork mechanism, and a Huygenian eyepiece (one actually constructed by Huygens in the 17th century and presented to the Society by Newton). In 1860 de la Rue took his invention at his own expense on an expedition to Rivabellosa Spain with the hope of photographing a total solar eclipse to occur on July 18th. The photographs de la Rue took represent the first extended series of photographic observations of the Sun over a solar cycle.
As de la Rue prepared his report for the Royal Society, presented in this paper, George Airy insisted upon the import of reproducing the original photographs without any alteration whatsoever. Airy believed that photography could standardize observation and argued that "exact facsimiles of the two eclipse photographs [were] infinitely more important than composites or retouched plates" (Pang, Empire and the Sun, 93). "De la Rue made two facsimile engravings of his photographs but it was very difficult work. Just copying the photographs took months: it was 'tolerable easy' to make copies 'which show the results fair well' when examined by eye, but copies for reproduction had to be stronger and more carefully made" (ibid, 94). The two facsimile engravings are included among the 13 de la Rue plates, a number of which are also hand-colored. Item #837
CONDITION & DETAILS: London: Taylor and Francis, Printers to the Royal Society. Complete extract. (11.5 x 9.25 inches; 288 x 231mm). pp. 333-416; In-text illustrations throughout; 14 plates, 4 large fold-out. Bright and clean throughout the text. The plates are somewhat toned at the margins. Very good condition.
Price: $375.00


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Getting your Card
New students
At this time, we are only producing ID Cards for SFU community members with a demonstrated need, e.g. Students living in SFU Residence or Staff working on campus.
If you have a need for a SFU ID Card, please complete the web form. If not, we look forward to producing your card when we return to in-person services! If you are unsure, please Contact Us.
Your card is automatically renewed whenever you enroll in courses. You must keep your card for the duration of your studies at SFU and thereafter as alumni. To learn more about your SFU card and how to use it, see Managing your SFU Card.
Acceptable photo identification
To get your SFU ID card, you must present one of the following valid photo IDs with your full name and date of birth in English:
- Passport
- Birth certificate*
- Driver's licence
- Certificate of Indian Status
- GoCard (must be presented with birth certificate or CareCard)
- Federal government employee ID
- Provincial government employee ID
- Municipal government employee ID
- Canadian citizenship certificate*
- Permanent resident card
*Must be presented with photo ID, if photo not included.
Photo standards
- Photograph must be taken on a plain white background
- Photograph taken must show a full head
- Head coverings (eg, hats, headphones or masks) are not allowed unless worn for religious beliefs or medical reasons
- Tinted prescription glasses may be worn as long as the eyes are clearly visible
- Sunglasses may not be worn
- Smiling is allowed
- Photograph must not be altered in any way
- Photograph must reflect current appearance