GH and the cardiovascular system: an update on a topic at heart

In this review, the importance of growth hormone (GH) for the maintenance of normal cardiac function in adult life is discussed. Physiological effects of GH and underlying mechanisms for interactions between GH and insulin-like growth factor I (IGF-I) and the cardiovascular system are covered as well as the cardiac dysfunction caused both by GH excess (acromegaly) and by GH deficiency in adult hypopituitary patients. In both acromegaly and adult GH deficiency, there is also increased cardiovascular morbidity and mortality possibly linked to aberrations in GH status. Finally, the status of the GH/IGF-I system in relation to heart failure and the potential of GH as a therapeutic tool in the treatment of heart failure are reviewed in this article. © 2014 The Author(s)

SIMBOLI, COMUNICAZIONE E MARKETING RELIGIOSO

Il simbolismo religioso oggigiorno costituisce un argomento di grande interesse per gli ecclesiasticisti, ma anche per gli studiosi delle varie branche del diritto e non solo, in quanto abbraccia delle problematiche \u201cumane\u201d, relazionali, politiche, economiche, amministrative e giurisprudenziali riguardanti la societ\ue0 nel suo pi\uf9 ampio aspetto. Il simbolo religioso pu\uf2 essere un oggetto, un capo di vestiario, o anche una prassi, un comportamento che in astratto o in concreto viene direttamente collegato ad una determinata confessione fideistica. Attraverso una sorta di \u201ctrasfigurazione simbolica\u201d, un singolo o una collettivit\ue0 si riconoscono, con pi\uf9 o meno intensit\ue0, in \u201cquella\u201d immagine sacra, assumendola come elemento della propria personalit\ue0 e socialit\ue0, come terreno delle proprie radici storico \u2013 culturali; la stessa crea un legame tra soggetti che si accomunano per avere una stessa credenza, che va protetta e riservata. Il simbolo religioso, al tempo stesso, \ue8 anche generatore di conflitti, perch\ue9 se da un lato unisce coloro che in quel simbolo si identificano, dall\u2019altro separa ed allontana chi non ci si rispecchia, chi ha altri simboli \u201cda mostrare\u201d, chi non ne ha, creando forti tensioni sociali e dando vita a quella che \ue8 diventata una vera e propria \u201cguerra\u201d al simbolo e del simbolo. I dibattiti maggiormente sollevati rispetto ai simboli religiosi riguardano, ovviamente, l\u2019esibizione degli stessi negli spazi pubblici, poich\ue9 tale esposizione sembrerebbe causare una violazione della libert\ue0 religiosa di chi non \u201criconosce\u201d come proprio \u201cquel\u201d simbolo, nonch\ue9 del principio di laicit\ue0 dello Stato. \uc8 innegabile che tale argomento inneschi contraddizioni interpretative ed ideologiche all\u2019interno dei moderni ordinamenti, poich\ue9 gli atteggiamenti \u201claici\u201d rispetto al diritto di libert\ue0 religiosa possono essere completamente differenti. A tal fine vengono rappresentante nel lavoro di ricerca alcune tra le principali sentenze che riguardano l\u2019ostensione di determinati simboli ed il conseguente bilanciamento con i principi giuridici e culturali dell\u2019ordinamento di riferimento. Casi tipici sono le controversie sorte in Italia, Francia, Svizzera, Turchia, in alcuni casi sfociati innanzi alla Corte Europea dei Diritti dell\u2019Uomo, la quale modella il proprio modus operandi a seconda del contesto nazionale, storico e culturale. In Italia, ad esempio, \ue8 emblematica la querelle dell\u2019esposizione del crocifisso, in particolar modo nelle scuole pubbliche, nelle aule giudiziarie e nei seggi elettorali, ma sono state affrontate anche questioni inerenti al velo islamico e ad ulteriori simboli religiosi legati a confessioni che maggiormente ricoprono un ruolo importante all\u2019interno delle societ\ue0 contemporanee. La seconda parte del lavoro di tesi \ue8 orienta ad uno studio potremmo dire \u201cdinamico\u201d del fattore religioso e del suo essere presenza all\u2019interno della comunit\ue0. Il simbolo religioso \ue8 lo strumento che la confessione utilizza per comunicare ed \u201carrivare\u201d ai propri fedeli. Da questo assunto, la scrivente ha svolto uno studio sulla semiotica del segno in generale, per poi giungere a quello religioso, costatando come il significato dello stesso possa mutare a seconda dell\u2019ambito sociale ed etnico, ma anche a seconda della persona che ne \ue8 il destinatario. Ci si \ue8 poi soffermati sulle modalit\ue0 di comunicazione sociale della Chiesa Cattolica in Italia, in quanto religione di maggioranza, evitando polemiche e problematiche legate al dato che la stessa, indiscutibilmente per storia e cultura, \u201coccupi\u201d molto spazio, anche rispetto ad altre confessioni, nell\u2019ambito dei mass media. Sulla scia argomentativa dei \u201cmessaggi\u201d religiosi, obbligatoria \ue8 stata una riflessione sulla libert\ue0 di espressione, in particolare la satira ed i suoi relativi (ed eventuali) limiti in ambito confessionale. \uc8 importante comprendere che anche nell\u2019elaborare un paradosso o una vignetta, occorre operare nella conoscenza dell\u2019altro, poich\ue9 in alcuni casi l\u2019ignoranza su determinati principi e credenze, potrebbe provocare gravi offese al sentimento religioso e dunque alla persona che si indentifica in esso. I simboli, dunque, sono parte integrante delle fedi e delle relative pratiche, pertanto anche di colui che \u201ccrede\u201d, al punto da plasmare l\u2019identit\ue0 di esso in ogni aspetto della vita quotidiana. Il trasmigrare dal mero piano spirituale all\u2019ambito sociale conduce i simboli religiosi ad \u201cinvadere\u201d addirittura la sfera economica, rilevando la capacit\ue0 degli stessi di influenzare l\u2019agire del soggetto che \ue8, contemporaneamente, uomo e fedele. Interessante, infatti, \ue8 apparso analizzare l\u2019interazione tra marketing e religione, con particolare attenzione all\u2019utilizzo dei simboli religiosi all\u2019interno delle campagne pubblicitarie, nonch\ue9 nelle operazioni di tipo commerciale come l\u2019acquisto di determinati prodotti. Dallo studio effettuato si evidenzia come i simboli religiosi non siano pi\uf9 di esclusivo dominio delle confessioni religiose, gli stessi infatti vengono spessi utilizzati come strumenti dotati di credibilit\ue0 per attirare il cliente, spingendolo ad acquistare prodotti che rispecchino la loro religiosit\ue0 e gli diano modo di essere maggiormente \u201cobbediente\u201d ai precetti religiosi, come nel particolare caso dell\u2019alimentazione. Riguardo al lavoro di ricerca svolto, si \ue8 giunti alla conclusione che una societ\ue0 nell\u2019affrontare il suo status di \u201cmulticulturale\u201d, deve essere capace di individuare e tutelare le differenze tra le culture e le religioni che vi coabitano. \uc8 necessario che gli ordinamenti, anche con la collaborazione delle confessioni religiose stesse, elaborino e concretizzino strumenti atti a far conoscere e rispettare le differenti etnie ed i simboli rappresentativi delle stesse, a gestirne le relative controversie e a creare una concreta integrazione nei vari aspetti della vita sociale, giuridica ed economica

Cardiovascular abnormalities and impaired exercise performance in adolescents with congenital adrenal hyperplasia

Context: Patients with classic Congenital Adrenal Hyperplasia (CAH) are treated with lifelong glucocorticoids (GCS). Cardiovascular (CV) and metabolic effects of such therapy in adolescents have never been quantified. Objective: To investigate left ventricular (LV) morphology, function and exercise performance in adolescents with CAH. Design and Setting: cross-sectional and controlled study conducted at a tertiary referral centre. Patients: Twenty patients with classic CAH (10 females) aged 13.6±2.5 years and 20 healthy controls comparable for sex and pubertal status were enrolled in the study and compared to a group of 18 patients without CAH receiving a similar dose of GCS for Juvenile Idiopathic Arthritis (JIA). Main Outcomes Measures: Echocardiographic assessment and symptom-limited exercise testing were performed. Anthropometric, hormonal and biochemical parameters were also measured. Results: Compared to healthy controls, patients with CAH exhibited an increased BMI (p<0.001), waist-to-height ratio (p<0.001), percentage of body fat (p<0.001) as well as higher insulin concentrations and HOMA index even after adjustment for BMI (p=0.03 and p=0.05, respectively). Moreover, CAH patients exhibited an impaired exercise capacity as shown by reduced peak workload (99±27 vs 126±27 W, p<0.01) and higher systolic blood pressure response at peak (156±18 vs 132±11 mmHg, p<0.01; Δ=45±24 vs 22±10 mmHg, p=0.05) with respect to healthy controls. CAH males displayed mild LV diastolic dysfunction as documented by significant prolongation of both isovolumic relaxation time (IRT) (118±18 vs 98±11ms, p<0.05) and mitral deceleration time (MDT) (138±25 vs 111±15 ms, p<0.01). No significant differences in CV function were found between CAH and JIA patients. Conclusion: Adolescents with CAH exhibit impaired exercise performance and enhanced systolic blood pressure response during exercise. In our population, such abnormalities appear related to GCS therapy rather than CAH per se. CAH males, but no females, present mild LV diastolic dysfunction that correlates with testosterone concentrations suggesting a sex hormone related difference

The impact of gender in cardiovascular medicine: Lessons from the gender/sex-issue in heart failure

Heart Failure (HF) is a major healthcare issue, given its high prevalence and incidence, the rate of comorbidities, the related high health-care costs and its poor outcome. In the last years mounting evidence revealed several differences between men and women affected by this clinical condition. Apart from the well-known difference in phenotype (HF with reduced ejection fraction (HFrEF) occurs more commonly in men, and HF with preserved ejection fraction (HFpEF) is more frequent in women) other relevant sex-related issues dwell upon epidemiology, presentation, risk stratification and management. These differences shed new lights on the possibility to consider HF as a prototype of the impact of gender/sex issue in cardiovascular medicine. A call for action and future strategies might help in the achievement of a cleaver patient-care

Antithrombotic therapy in patients undergoing transcatheter aortic valve replacement: the complexity of the elderly

Along with epidemiologic transitions of the global population, the burden of aortic stenosis (AS) is rapidly increasing and transcatheter aortic valve replacement (TAVR) has quickly spread; indeed, it is nowadays also employed in treating patients with AS at intermediate operative risk. Nonetheless, the less invasive interventional strategy still carries relevant issues concerning post-procedural optimal antithrombotic strategy, given the current indications provided by guidelines are not completely supported by evidence-based data. Geriatric patients suffer from high bleeding and thromboembolic risks, whose balance is particularly subtle due to the presence of concomitant conditions, such as atrial fibrillation and chronic kidney disease, that make the post-TAVR antithrombotic management particularly insidious. This scenario is further complicated by the lack of specific evidence regarding the 'real-life' complex conditions typical of the geriatric syndromes, thus, the management of such a heterogeneous population, ranging from healthy ageing to frailty, is far from being defined. The aim of the present review is to summarize the critical points and the most updated evidence regarding the post-TAVR antithrombotic approach in the geriatric population, with a specific focus on the most frequent clinical settings

Validation of the ONKOTEV Risk Prediction Model for Venous Thromboembolism in Outpatients With Cancer

Importance: The assessment of the risk of venous thromboembolism (VTE) among outpatients with cancer represents an unsolved topic. Current international guidelines recommend primary prophylaxis for patients at intermediate to high risk of VTE, indicated by a Khorana score of 2 or more. A previous prospective study developed the ONKOTEV score, a 4-variable risk assessment model (RAM) consisting of a Khorana score of more than 2, metastatic disease, vascular or lymphatic compression, and previous VTE event. Objective: To validate the ONKOTEV score as a novel RAM to assess the risk of VTE among outpatients with cancer. Design, setting, and participants: ONKOTEV-2 is a noninterventional prognostic study conducted in 3 European centers located in Italy, Germany, and the United Kingdom among a prospective cohort of 425 ambulatory patients with a histologically confirmed diagnosis of a solid tumor who were receiving active treatments. The total study duration was 52 months, with an accrual period of 28 months (from May 1, 2015, to September 30, 2017) and an overall follow up-period of 24 months (data were censored September 30, 2019). Statistical analysis was performed in October 2019. Exposures: The ONKOTEV score was calculated for each patient at baseline by collecting clinical, laboratory, and imaging data from tests performed for routine practice. Each patient was then observed to detect any thromboembolic event throughout the study period. Main outcomes and measures: The primary outcome of the study was the incidence of VTE, including deep vein thrombosis and pulmonary embolism. Results: A total of 425 patients (242 women [56.9%]; median age, 61 years [range, 20-92 years]) were included in the validation cohort of the study. The cumulative incidences for the risk of developing VTE at 6 months were 2.6% (95% CI, 0.7%-6.9%), 9.1% (95% CI, 5.8%-13.2%), 32.3% (95% CI, 21.0%-44.1%), and 19.3% (95% CI, 2.5%-48.0%), respectively, among 425 patients with an ONKOTEV score of 0, 1, 2, and greater than 2 (P < .001). The time-dependent area under the curve at 3, 6, and 12 months was 70.1% (95% CI, 62.1%-78.7%), 72.9% (95% CI, 65.6%-79.1%), and 72.2% (95% CI, 65.2%-77.3%), respectively. Conclusions and relevance: This study suggests that, because the ONKOTEV score has been validated in this independent study population as a novel predictive RAM for cancer-associated thrombosis, it can be adopted into practice and into clinical interventional trials as a decision-making tool for primary prophylaxis

Anabolic/Catabolic Imbalance in Chronic Heart Failure

A metabolic imbalance between anabolic drive and catabolic forces is commonly observed in chronic heart failure (CHF) patients, with the latter prevailing over anabolic hormones. Moreover, anabolic deficiencies are independent markers of poor prognosis. This finding represents a solid background for the implementation of therapeutic trials based on replacement therapy. The somatotropic axis (GH/IGF-1) is the most powerful anabolic axis of the body and its decline is related with a poor outcome and a worse clinical status. Growth hormone (GH) administration may enter the therapeutic arena as adjunctive treatment in patients affected by CHF and GH/IGF-1 deficiency. The T.O.S.CA. project aims at investigating the relationship between CHF and hormonal deficiency