Background Evidence and Research Perspectives

Recent epidemiological analyses suggest that incident cancer may be more common among patients with preexisting heart failure (HF) than in patients without HF. Arguments against this notion have been the increased chance of co-occurrence of 2 high-prevalence conditions and increased tumor detection in patients with HF because of intensified medical observation. However, biological data lend support to the hypothesis that HF is an oncogenic condition. Neurohormonal activation has been related to cancer initiation, progression, and dissemination by studies not specifically focusing on HF, which are now reappraised in the light of the emerging evidence that tumors are diagnosed more often in HF than control cohorts. Furthermore, a thought-provoking scenario to be considered is that a systemically perturbed milieu, where low-grade inflammation plays a primary role, leads to both HF and malignancy, thus connecting 1 disease to another. Postischemic HF has been shown to promote tumor growth in an animal model. Exploring these and other pathways potentially linking HF to malignancy is a new and exciting field of research, with the ultimate goal of answering the question of whether HF does promote cancer

The Focus-activity Framework for Evaluating PSS Cooperation Readiness of Manufacturing Firms

For manufacturing companies venturing the first steps on the Servitization roadmap, it may be difficult to imagine how an integrated approach of Product and Service elements could support the strategic goals efficiently. If Service tasks, roles, units and organizational structure are still developing and emerging from the Product business activities, the design of Product-Service cooperation as well is promising, as the way is unclear. For these companies, it seems to be important to understand their current status of Product-Service cooperation at first, before starting to design integration activities. Therefore, this paper presents a framework which is designed to help companies identify their current status – and strategic objectives later on – at two dimensions: a) the Structural Focus of Product and Service business within the company, and b) the Cooperation Activities which are undertaken by Product and Service representatives. By the means of a case study in the Italian luxury textile sector, a first validation of the model is conducted, assessing the static and dynamic characteristics of Product and Service business with involvement of an Italian textile company

Le acque termali e le architetture per il benessere

L'articolo descrive nella prima parte la storia e le modifiche che hanno interessato le principali stazioni termali della Valle d'Aosta, nella seconda parte si concentra sulle architetture del benessere e i centri wellness nei resort analizzati attraverso la loro ubicazione, le caratteristiche stilistiche e i material

Yield of bone scintigraphy screening for transthyretin-related cardiac amyloidosis in different conditions. Methodological issues and clinical implications

Background Transthyretin-related cardiac amyloidosis (TTR-CA) is thought to be particularly common in specific at-risk conditions, including aortic stenosis (AS), heart failure with preserved ejection fraction (HFpEF), carpal tunnel syndrome (CTS) and left ventricular hypertrophy or hypertrophic cardiomyopathy (LVH/HCM). Methods We performed a systematic revision of the literature, including only prospective studies performing TTR-CA screening with bone scintigraphy in the above-mentioned conditions. Assessment of other forms of CA was also evaluated. For selected items, pooled estimates of proportions or means were obtained using a meta-analytic approach. Results Nine studies (3 AS, 2 HFpEF, 2 CTS and 2 LVH/HCM) accounting for 1375 screened patients were included. One hundred fifty-six (11.3%) TTR-CA patients were identified (11.4% in AS, 14.8% in HFpEF, 2.6% in CTS and 12.9% in LVH/HCM). Exclusion of other forms of CA and use of genetic testing was overall puzzled. Age at TTR-CA recognition was significantly older than that of the overall screened population in AS (86 vs. 83 years, p = .04), LVH/HCM (75 vs. 63, p < .01) and CTS (82 vs. 71), but not in HFpEF (83 vs. 79, p = .35). In terms of comorbidities, hypertension, diabetes and atrial fibrillation were highly prevalent in TTR-CA-diagnosed patients, as well as in those with an implanted pacemaker. Conclusions Screening with bone scintigraphy found an 11-15% TTR-CA prevalence in patients with AS, HFpEF and LVH/HCM. AS and HFpEF patients were typically older than 80 years at TTR-CA diagnosis and frequently accompanied by comorbidities. Several studies showed limitations in the application of recommended TTR-CA diagnostic algorithm, which should be addressed in future prospective studies

Distinguishing ventricular septal bulge versus hypertrophic cardiomyopathy in the elderly

The burgeoning evidence of patients diagnosed with sigmoidal hypertrophic cardiomyopathy (HCM) later in life has revived the quest for distinctive features that may help discriminate it from more benign forms of isolated septal hypertrophy often labelled ventricular septal bulge (VSB). HCM is diagnosed less frequently than VSB at older ages, with a reversed female predominance. Most patients diagnosed with HCM at older ages suffer from hypertension, similar to those with VSB. A positive family history of HCM and/or sudden cardiac death and the presence of exertional symptoms usually support HCM, though they are less likely in older patients with HCM, and poorly investigated in individuals with VSB. A more severe hypertrophy and the presence of left ventricular outflow obstruction are considered diagnostic of HCM, though stress echocardiography has not been consistently used in VSB. Mitral annulus calcification is very prevalent in both conditions, whereas a restrictive filling pattern is found in a minority of older patients with HCM. Genetic testing has low applicability in this differential diagnosis at the current time, given that a causative mutation is found in less than 10% of elderly patients with suspected HCM. Emerging imaging modalities that allow non-invasive detection of myocardial fibrosis and disarray may help, but have not been fully investigated. Nonetheless, there remains a considerable morphological overlap between the two conditions. Comprehensive studies, particularly imaging based, are warranted to offer a more evidence-based approach to elderly patients with focal septal thickening

Teratoma testicular bilateral sincrónico: reporte de un caso y revisión de la literatura

ResumenAntecedentesEl cáncer testicular de células germinales es la neoplasia más frecuente en hombres de 15 a 35años de edad; es bilateral en el 2 al 3%, y sincrónico en el 20 al 25% de los casos.Caso clínicoMasculino de 19años de edad, con dolor abdominal y tumor palpable en mesogastrio. En la tomografía se encontró un tumor retroperitoneal, y por laboratorio se detectó elevación de α-fetoproteína, deshidrogenasa láctica y gonadotropina coriónica humana. En el ultrasonido testicular se identifican lesiones bilaterales. Se realizó laparotomía exploradora, identificándose tumor retroperitoneal irresecable, y se tomaron biopsias incisionales compatibles para tumor de células germinales mixto, con áreas de coriocarcinoma y carcinoma embrionario. Se administraron 6ciclos de quimioterapia con bleomicina, etopósido y cisplatino, obteniéndose una respuesta tumoral parcial. Posteriormente se realizó orquiectomía radical bilateral, con reporte patológico de teratoma bilateral sincrónico. Se inició segunda línea de quimioterapia con vincristina, etopósido, ifosfamida y platino; sin embargo, la enfermedad progresó, presentando diseminación metastásica y provocando el deceso del paciente.DiscusiónLos tumores de células germinales pueden presentarse en sitios primarios extragonadales. Es difícil distinguir un tumor de células germinales primario del retroperitoneo, de una enfermedad metastásica derivada de un tumor gonadal no detectado clínicamente, o que ha involucionado, situación que se describe en el caso clínico presentado.ConclusiónEl 90% de los pacientes diagnosticados con tumor de células germinales pueden ser curados; sin embargo, un retraso en el diagnóstico se correlaciona con una etapa clínica más avanzada y un pronóstico desfavorable.AbstractBackgroundTesticular germ-cell carcinoma is the most frequent neoplasm in males aged 15 to 35 years old. It is bilateral in 2% to 3%, and synchronous in 20% to 25% of the cases.Clinical caseThe case is presented of a 19 year-old male, with abdominal pain. Physical examination revealed abdominal mass in the umbilical region, and the computed tomography scan showed a retroperitoneal tumour, with α-fetoprotein, lactate dehydrogenase, and human chorionic gonadotropin above limits. Testicular ultrasound showed bilateral lesions. Exploratory laparotomy was performed, identifying an unresectable retroperitoneal tumour. Biopsies were taken, reporting mixed germ cell tumour composed of choriocarcinoma and embryonal carcinoma. Six cycles of chemotherapy were given, based on bleomycin, etoposide and cisplatin, with partial tumour response. Later on, the patient underwent bilateral radical orchiectomy, with pathology reporting a synchronous bilateral testicular teratoma. A second line of chemotherapy was given, based on vincristine, etoposide, ifosfamide and cisplatinum. Nevertheless, the disease progressed, with metastatic dissemination and the patient died.DiscussionGerm cells tumours can present in primary extra-gonadal locations. It is difficult to distinguish a retroperitoneum primary germ cell tumour from metastatic disease of a clinically undetected gonadal tumour or one that has regressed, like the situation described in the case presented.ConclusionsNinety percent of patients diagnosed with germ cell tumours can be cured. However, delay in diagnosis correlates with an advanced clinical stage and poor prognosis

Performance of prognostic risk scores in chronic heart failure patients enrolled in the European Society of Cardiology Heart Failure long-term registry

[Abstract] Objectives. This study compared the performance of major heart failure (HF) risk models in predicting mortality and examined their utilization using data from a contemporary multinational registry. Background. Several prognostic risk scores have been developed for ambulatory HF patients, but their precision is still inadequate and their use limited. Methods. This registry enrolled patients with HF seen in participating European centers between May 2011 and April 2013. The following scores designed to estimate 1- to 2-year all-cause mortality were calculated in each participant: CHARM (Candesartan in Heart Failure-Assessment of Reduction in Mortality), GISSI-HF (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico-Heart Failure), MAGGIC (Meta-analysis Global Group in Chronic Heart Failure), and SHFM (Seattle Heart Failure Model). Patients with hospitalized HF (n = 6,920) and ambulatory HF patients missing any variable needed to estimate each score (n = 3,267) were excluded, leaving a final sample of 6,161 patients. Results. At 1-year follow-up, 5,653 of 6,161 patients (91.8%) were alive. The observed-to-predicted survival ratios (CHARM: 1.10, GISSI-HF: 1.08, MAGGIC: 1.03, and SHFM: 0.98) suggested some overestimation of mortality by all scores except the SHFM. Overprediction occurred steadily across levels of risk using both the CHARM and the GISSI-HF, whereas the SHFM underpredicted mortality in all risk groups except the highest. The MAGGIC showed the best overall accuracy (area under the curve [AUC] = 0.743), similar to the GISSI-HF (AUC = 0.739; p = 0.419) but better than the CHARM (AUC = 0.729; p = 0.068) and particularly better than the SHFM (AUC = 0.714; p = 0.018). Less than 1% of patients received a prognostic estimate from their enrolling physician. Conclusions. Performance of prognostic risk scores is still limited and physicians are reluctant to use them in daily practice. The need for contemporary, more precise prognostic tools should be considered

Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure

AIMS: To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation (AF) in chronic heart failure (CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers (BB). METHODS: We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB. RESULTS: A total of 903 patients were evaluated (mean age 68\ub112 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients 6460 and 6577 years, respectively. Besides the older age, patients with AF had more symptoms (NYHA II-III 60 vs. 44%), lower prevalence of dyslipidemia (23 vs. 37%), coronary artery disease (28 vs. 52%) and left bundle branch block (9 vs. 16%). On the contrary, they more frequently presented with an idiopathic etiology (50 vs. 24%), a history of valve surgery (13 vs. 4%) and received overall more devices implantation (31% vs. 21%). The use of disease-modifying medications (i.e. BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF (72 vs. 80% e 71 vs. 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics (87 vs. 69%) and digoxin (51 vs. 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm (45% vs. 34%, p value <0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of all-cause mortality, the univariate relationship between AF and death (HR 1.49, 95% CI 1.15-1.92) became not statistically significant (HR 0.98, 95% CI 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with sinus rhythm not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with sinus rhythm receiving BB therapy. CONCLUSIONS: AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis

Clinical Outcomes in Patients With Nonobstructive, Labile, and Obstructive Hypertrophic Cardiomyopathy

Background-\u2014Hypertrophic cardiomyopathy (HCM) is a common inherited cardiac disease characterized by varying degrees of left ventricular outflow tract obstruction. In a large cohort, we compare the outcomes among 3 different hemodynamic groups. Methods and Results-\u2014We prospectively enrolled patients fulfilling standard diagnostic criteria for HCM from January 2005 to June 2015. Detailed phenotypic characterization, including peak left ventricular outflow tract pressure gradients at rest and after provocation, was measured by echocardiography. The primary outcome was a composite cardiovascular end point, which included new-onset atrial fibrillation, new sustained ventricular tachycardia/ventricular fibrillation, new or worsening heart failure, and death. The mean follow-up was 3.42.8 years. Among the 705 patients with HCM (mean age, 5215 years; 62% men), 230 with obstructive HCM were older and had a higher body mass index and New York Heart Association class. The 214 patients with nonobstructive HCM were more likely to have a history of sustained ventricular tachycardia/ventricular fibrillation and implantable cardioverter defibrillator implantation. During follow-up, 121 patients experienced a composite cardiovascular end point. Atrial fibrillation occurred most frequently in the obstructive group. Patients with nonobstructive HCM had more frequent sustained ventricular tachycardia/ventricular fibrillation events. In multivariate analysis, obstructive (hazard ratio, 2.80; 95% confidence interval, 1.64\u20134.80) and nonobstructive (hazard ratio, 1.94; 95% confidence interval, 1.09\u20133.45) HCM were associated with more adverse events compared with labile HCM. Conclusions-\u2014Nonobstructive HCM carries notable morbidity, including a higher arrhythmic risk than the other HCM groups. Patients with labile HCM have a relatively benign clinical course. Our data suggest detailed sudden cardiac death risk stratification in nonobstructive HCM and monitoring with less aggressive management in labile HCM