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Heart failure with preserved ejection fraction (HFpEF) is a widely heterogeneous clinical condition. Left ventricular diastolic dysfunction is the leading etiology of HFpEF, but there might be patients presenting with a predominant disease of the left atrium (LA). We report a case of HFpEF secondary to a stiff LA, in which we corroborated invasive hemodynamic assessment with LA strain analysis. Pathognomonic, tall V-waves were observed in the wedge position in the absence of mitral regurgitation and with a near-normal QRS-gated, pre-V-wave pressure, indicating that left ventricular diastolic dysfunction was not a major issue in this case. These hemodynamic findings were mirrored by very low LA strain values, compatible with a stiff and noncompliant chamber

In heart failure (HF) sleep problems and sleep-related breathing disorders are frequently reported and are associated with poor prognosis. However, only few large clinical studies have investigated this issue in heart failure through breathing pattern analysis by polysomnography., Background: In heart failure (HF) sleep problems and sleep-related breathing disorders are frequently reported and are associated with poor prognosis. However, only few large clinical studies have investigated this issue in heart failure through breathing pattern analysis by polysomnography. Methods and results: 370 HF patients, with either moderate-severe reduced ejection fraction or with clinical decompensation, consecutively referred to 10 participating cardiology centers, have been enrolled in the PROMISES Study, an Italian project aimed at generating a large, multidisciplinary database of anthropometric, clinical, echocardiographic and sleep data, the last derived from overnight unattended cardio-respiratory polysomnography in HF patients. Obstructive sleep apnea was the most frequent form of sleep related breathing disorders observed in our cohort (35.4% with an AHI cutoff of 15). The possible determinants of sleep related breathing disorders were analyzed through stepwise logistic regression analysis and two multivariate models showing that a markedly reduced left ventricular ejection fraction was the most important factor associated with central sleep apneas (OR = 7.7 for AHI cutoff = 15 and LVEF ≤ 35%) together with male gender and increasing age. Conventional risk factors for obstructive sleep apnea did not identify HF patients affected by this condition. Conversely, a greater neck circumference was associated with an increased risk for central apneas. Conclusions: Our paper offers a deeper insight into the features of SRBD and its determinants in HF patients, leading in turn to a better clinical management of these comorbid patients.

AIMS: Risk stratification in heart failure (HF) is crucial for clinical and therapeutic management. A multiparametric approach is the best method to stratify prognosis. In 2012, the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score was proposed to assess the risk of cardiovascular mortality and urgent heart transplantation. The aim of the present study was to compare the prognostic accuracy of MECKI score to that of HF Survival Score (HFSS) and Seattle HF Model (SHFM) in a large, multicentre cohort of HF patients with reduced ejection fraction. METHODS AND RESULTS: We collected data on 6112 HF patients and compared the prognostic accuracy of MECKI score, HFSS, and SHFM at 2- and 4-year follow-up for the combined endpoint of cardiovascular death, urgent cardiac transplantation, or ventricular assist device implantation. Patients were followed up for a median of 3.67 years, and 931 cardiovascular deaths, 160 urgent heart transplantations, and 12 ventricular assist device implantations were recorded. At 2-year follow-up, the prognostic accuracy of MECKI score was significantly superior [area under the curve (AUC) 0.781] to that of SHFM (AUC 0.739) and HFSS (AUC 0.723), and this relationship was also confirmed at 4 years (AUC 0.764, 0.725, and 0.720, respectively). CONCLUSION: In this cohort, the prognostic accuracy of the MECKI score was superior to that of HFSS and SHFM at 2- and 4-year follow-up in HF patients in stable clinical condition. The MECKI score may be useful to improve resource allocation and patient outcome, but prospective evaluation is needed

Questo manuale offre una prospettiva ampia sullo sviluppo dell’individuo, in cui la trattazione delle ricerche e delle teorie prodotte sui processi di sviluppo motorio, emotivo, affettivo, cognitivo, comunicativo-linguistico, morale e sociale tiene conto della complessità dei diversi contesti di crescita: da quelli tradizionali, come la scuola e la famiglia, alle comunità virtuali, in cui stanno emergendo modalità e processi nuovi di comunicazione e di apprendimento, funzionali e disfunzionali.

Il capitolo presente alcune sfide evolutive a cui sono chiamati genitori e minori migranti, che si trovano a misurarsi con un contesto sociale multiculturale, nel quale spesso la loro appartenza è minoritaria; sfide il cui esito permette di giungere a forme più o meno adeguate di adattamento e che naturalmente subiscono modulazioni – anche rilevanti – a seconda dei cambiamenti di significato attribuiti alle situazioni, delle diverse strategie di coping utilizzate e della diversa tolleranza allo stress derivante dai processi d’acculturazione . Una prima sfida posta dalle società multiculturali, che coinvolge in prima persona i genitori migranti, è quella che riguarda i processi di accudimento e di cura del bambino. Un'ulteriore sfida, presentata nel testo, è quella rappresentata dal processo di definizione dell'identità da parte dei minori con background migratorio, che ha come obiettivo finale quello di mantenere quell’unità del Sé pur nelle diverse tradizioni tradizioni in cui si trovano a vivere, unità assolutamente necessaria per il loro benessere e il loro sviluppo.

Objective: To analyze the quality of the family interactions of adolescents and the involvement in situations of school bullying. Methods: A population-based cross-sectional study involving 2,354 students (girls = 50.7%, mean age M = 14.5 years, SD = 2.0 years) of 11 primary schools in a city of the interior of Minas Gerais. The study sample was defined by stratum selection (schools), using the Probability Proportional to Size method. The data collection occurred through collective application of two scales, one to identify behaviors of bullying/victimization and another to measure the quality of family interactions of the adolescents. The analysis procedures included: descriptive statistical analysis, analysis of variance (ANOVA) and logistic regression. Results: The study found a prevalence of 10.3% of the aggressors students, 10.1% of the victims and 5.4% of the victims-aggressors in the sample. It was found that students not involved in bullying situations had better family interactions when compared to students identified as aggressors, victims and victims-aggressors. Effects of the “rules and monitoring” aspect (OR: 1,21; p = 0,001) in the family context were identified as protective for bullying or victimization. The “physical punishment” (OR: 0,84, p = 0,001) and “negative communication” (OR: 0,53; p = 0,001) aspects were associated with a greater possibility of bullying or victimization among the students. Conclusions: It was confirmed that the quality of family interactions influences the involvement of the students in bullying situations. Implications for the health area were discussed from identified risk and protection indicators.

Il contributo si propone di analizzare l'utilizzo delle tecnologie in ambito scolastico evidenziandone elementi di risorsa e di vincolo

Il capitolo offre una panoramica delle principali teorie e dei modelli neuropsicologici che forniscono una descrizione e una interpretazione dei processi di acquisizione della lettura, della scrittura, del calcolo e della risoluzione di problemi. Si analizzano quindi le traiettorie tipiche di apprendimento, a partire dai precursori della literacy e della numeracy, per arrivare ad una descrizione dei processi cognitivi coinvolti nei compiti considerati. Vengono inoltre fornite le conoscenze di base per comprendere i disturbi specifici di apprendimento, illustrando le principali ipotesi eziologiche formulate in letteratura e fornendo indicazioni in merito alle procedure diagnostiche e ai trattamenti identificati dai documenti prodotti dalle consensus conference organizzate su queste tematiche.

Scopo di questo contributo è mantenere sempre viva l’attenzione alla interconnessione tra fattori di rischio e fattori protettivi presenti in quei contesti di crescita caratterizzati da difficoltà e fragilità genitoriale. Il concetto di fragilità genitoriale, rispetto ad altri termini con significato marcatamente clinico, richiama la presenza di difficoltà e di sofferenza psichica, sociale ed educativa nei genitori che influenzano o potrebbero influenzare le traiettorie di sviluppo dei figli, evolvendo verso forme di disagio croniche e di disadattamento o che, viceversa potrebbero modificarsi positivamente attraverso il rafforzamento delle risorse e delle competenze individuali e familiari. Fragile, quindi, nel senso di delicato, debole, debilitato, cagionevole, gracile e, quindi, soggetto a rompersi o a spezzarsi. Ma, anche, nel senso di bisognoso, necessitante, richiedente, incompleto e sprovvisto di risorse per far fronte alle difficoltà e agli ostacoli. Tra le tante forme di fragilità genitoriale richiede attenzione e lungimirante riflessione in chiave preventiva, quella che si manifesta attraverso azioni omissive e commissive nei confronti dei figli che vengono dimenticati e trascurati o diventano bersaglio di violenza fisica, verbale e sessuale. Ci occuperemo in questo capitolo di genitori fragili, violenti e trascuranti non per farne un identikit o per descriverne le caratteristiche psicologiche o familiari ma piuttosto per cogliere quell’intreccio tra fattori negativi e risorse utili a delineare eventuali azioni di supporto e di sostegno finalizzate al recupero di traiettorie evolutive positive per i figli. La spinta a sostenere, anche in una prospettiva preventiva, la genitorialità fragile nasce dalla consapevolezza dei gravi danni che potrebbero correre bambini e bambine costretti a vivere quotidianamente con genitori che, spesso inconsapevolmente altre volte intenzionalmente, erodono la costruzione del senso di fiducia dei figli, provocando soffer

Background Excessive exercise-induced hyperventilation and high prevalence of exercise oscillatory breathing (EOB) are present in patients with post-capillary pulmonary hypertension (PH) complicating left heart disease (LHD). Patients with pre-capillary PH have even higher hyperventilation but no EOB. We sought to determine the impact of a pre-capillary component of PH on ventilatory response to exercise in patients with PH and left heart disease. Methods We retrospectively compared patients with idiopathic or heritable pulmonary arterial hypertension (PAH, n = 29), isolated post-capillary PH (IpcPH, n = 29), and combined post- and pre-capillary PH (CpcPH, n = 12). Diastolic pressure gradient (DPG = diastolic pulmonary artery pressure − pulmonary wedge pressure) was used to distinguish IpcPH (DPG <7 mm Hg) from CpcPH (DPG ≥7 mm Hg). Results Pulmonary vascular resistance (PVR) was higher in PAH, intermediate in CpcPH, and low in IpcPH. All patients with CpcPH but 1 had PVR >3 Wood unit. Exercise-induced hyperventilation (high minute ventilation over carbon dioxide production, low end-tidal carbon dioxide) was marked in PAH, intermediate in CpcPH, and low in IpcPH (p < 0.001) and correlated with DPG and PVR. Prevalence of EOB decreased from IpcPH to CpcPH to PAH (p < 0.001). Conclusions Patients with CpcPH may have worse hemodynamics than patients with IpcPH and distinct alterations of ventilatory control, consistent with more exercise-induced hyperventilation and less EOB. This might be explained at least in part by the presence and extent of pulmonary vascular disease

Background Anemia is frequent in heart failure (HF), and it is associated with higher mortality. The predictive power of established HF prognostic parameters in anemic HF patients is unknown. Methods Clinical, laboratory, echocardiographic and cardiopulmonary-exercise-test (CPET) data were analyzed in 3913 HF patients grouped according to hemoglobin (Hb) values. 248 (6%), 857 (22%), 2160 (55%) and 648 (17%) patients had very low (< 11 g/dL), low (11–12 for females, 11–13 for males), normal (12–15 for females, 13–15 for males) and high (> 15) Hb, respectively. Results Median follow-up was 1363 days (606–1883). CPETs were always performed safely. Hb was related to prognosis (Hazard ratio (HR) = 0.864). No prognostic difference was observed between normal and high Hb groups. Peak oxygen consumption (VO2), ventilatory efficiency (VE/VCO2 slope), plasma sodium concentration, ejection fraction (LVEF), kidney function and Hb were independently related to prognosis in the entire population. Considering Hb groups separately, peakVO2 (very low Hb HR = 0.549, low Hb HR = 0.613, normal Hb HR = 0.618, high Hb HR = 0.542) and LVEF (very low Hb HR = 0.49, low Hb HR = 0.692, normal Hb HR = 0.697, high Hb HR = 0.694) maintained their prognostic roles. High VE/VCO2 slope was associated with poor prognosis only in patients with low and normal Hb. Conclusions Anemic HF patients have a worse prognosis, but CPET can be safely performed. PeakVO2 and LVEF, but not VE/VCO2 slope, maintain their prognostic power also in HF patients with Hb < 11 g/dL, suggesting CPET use and a multiparametric approach in HF patients with low Hb. However, the prognostic effect of an anemia-oriented follow-up is unknown.

Background Limited evidence exists on blood pressure (BP) responses to exercise in hypertensive subjects exposed to high altitude, and on the effects of antihypertensive treatment in this setting. We aimed to asses BP response to submaximal exercise in hypertensive lowlanders acutely exposed to high altitude, and the effects of a calcium antagonist-angiotensin receptor blocker combination in this condition. Methods 89 mild-hypertensive participants in HIGHCARE-ANDES study performed a six-minute walk test in 3 conditions: at sea-level off-treatment; at sea-level after 6 weeks of double-blind treatment with telmisartan 80mg + slow release nifedipine 30 mg or with placebo; on the first full day of permanence at 3260 m altitude under randomized treatment. Results The distance walked in 6 min was reduced by about 10% at high altitude in both groups (p < 0.001) without treatment-related differences. Systolic BP increased at altitude in both groups, remaining lower on telmisartan/nifedipine than on placebo both before and after exercise (p < 0.001).The exercise-induced increase in systolic BP at altitude was blunted by active treatment as compared to placebo (+ 32.0 ± 19.8 vs + 41.9 ± 23.3 mm Hg, p < 0.05). Diastolic BP was unchanged from sea-level to altitude in both groups, showing lower values on telmisartan/nifedipine than on placebo before and after exercise (p < 0.01). Oxygen saturation was similarly reduced in both groups before exercise at altitude, but after exercise it was higher on telmisartan/nifedipine than on placebo. Conclusions In mild hypertensives, acute exposure to high altitude enhances the BP response to exercise. Such an enhanced response is effectively reduced by telmisartan/nifedipine combination therapy, without affecting exercise performance.

Background-In patients with chronic heart failure, abnormal ventilation at cardiopulmonary testing (expressed by minute ventilation-to-carbon dioxide production, or VE/VCO2 slope, and resting end-tidal CO2 pressure) may derive either from abnormal autonomic or chemoreflex regulation or from lung dysfunction induced by pulmonary congestion. The latter hypothesis is supported by measurement of pulmonary capillary wedge pressure, which cannot be obtained routinely but may be estimated noninvasively by measuring transthoracic conductance (thoracic fluid content 1/kO) with impedance cardiography.Methods and Results-Preliminarily, in 9 patients undergoing invasive hemodynamics during cardiopulmonary testing, we demonstrated a significant relationship between VE/VCO2 slope and resting end-tidal CO2 pressure with baseline and peak pulmonary capillary wedge pressure. Later, noninvasive hemodynamic evaluation by impedance cardiography was performed before cardiopulmonary testing in 190 patients with chronic systolic heart failure and normal lung function (aged 67±3 years, 71% with ischemia, ejection fraction 32±7%, 69% with implantable cardioverter-defibrillator or cardiac resynchronization therapy). In this group, we determined the relationship between abnormal ventilation (VE/VCO2 slope and resting end-tidal CO2 pressure) and transthoracic conductance. In the whole population, thoracic fluid content values were significantly related to VE/VCO2 slope (R=0.63, P<0.0001) and to resting end-tidal CO2 pressure (R=-0.44, P<0.001).Conclusions-In patients with chronic heart failure, abnormal ventilation during exercise may be related in part to pulmonary congestion, as detected by resting baseline impedance cardiography.

The different roles of bullying participation (bully, follower, victim, defender of the victim, and outsider) have not been investigated in preschool children. The aims of this study were to use a peer-report measure to assess these roles and to investigate their associations with social competence among pre-schoolers. We also explored whether status among peers, indicated by being socially preferred, mediates the relationship between social competence and bullying roles. Three hundred twenty 3- to 6-year-old children participated in the study. Bullying roles and social preference were assessed by means of peer reports, whereas social competence was investigated with a Q-Sort methodology, based on observations in classrooms. Bullying was also assessed by means of teacher reports. The results showed quite a clear distinction among roles and a correspondence between peer and teacher assessments, except for the role of outsider. The role of defender was positively associated with social competence, whereas the other roles were negatively associated. In a subsample, social preference statistically predicted the role of bully and mediated between social competence and bullying. The findings are discussed in terms of the importance of assessing bullying and its correlates at a very young age, although roles may further develop when children grow up.

OBJECTIVE: Blood pressure (BP) measuring devices may become inaccurate at high altitude due to low barometric pressure. Aim of this study was to assess the changes in the accuracy of different types of BP measuring devices between sea level and high altitude, taking auscultatory measurements with mercury sphygmomanometer as reference. DESIGN AND METHOD: In the frame of HIGHCARE-ALPS project, we obtained multiple BP measurements in 39 healthy, normotensive volunteers (age:36.4 ± 8.5y, M/F:21/18), using a mercury (MER, reference), an aneroid (ANE), and two validated oscillometric devices [one for home (OSC-HBP; AND UA-767PC) and one for ambulatory (OSC-ABP; AND TM2430)] BP monitoring, at sea level and during acute exposure to high altitude (4559m, 437-439 Torr). BP measurements with the different devices were performed sequentially on the same arm in random order, consistent under both study conditions. RESULTS: Mean systolic (S) and diastolic (D)BP were higher at high altitude than at sea level (MER: 117.6/80.3 vs. 110.9/74.1 mmHg, p < 0.001) The mean differences in SBP between MER (reference) and the other devices at baseline and high altitude were 1.7 ± 6.5/0.6 ± 7.1 (OSC-ABP), -3.1 ± 5.3*/-3.8 ± 6.3* (ANE) and -1.2 ± 7.0/-5.0 ± 6.7* (OSC-HBP) respectively. The corresponding differences for DBP were -3.9 ± 5.9*/-4.5 ± 6.5* (OSC-ABP), -2.2 ± 5.1*-5.3 ± 6.7* (ANE) and -4.8 ± 7.6*/-1.8 ± 7.1 (OSC-HBP), (mmHg, *p < 0.01 vs. MER). The over or underestimations of BP values by tested devices as compared with MER were consistent and similar at sea level and high altitude, except for a greater underestimation of SBP by OSC-HBP (p = 0.01), and of DBP by ANE (p = 0.03) at altitude, and for a greater underestimation of DBP by OSC-HBP (p = 0.02) at sea level. In spite of the statistical significance, the absolute changes in the size of error between sea level and high altitude never exceeded 4 mmHg. The distribution of mean between-device differences within the group was

Blood pressure increases during acute exposure to high altitude in healthy humans. However, little is known on altitude effects in hypertensive subjects or on the treatment efficacy in this condition. Objectives of High Altitude Cardiovascular Research (HIGHCARE)-Andes Lowlanders Study were to investigate the effects of acute high-altitude exposure on 24-hour ambulatory blood pressure in hypertensive subjects and to assess antihypertensive treatment efficacy in this setting. One hundred untreated subjects with mild hypertension (screening blood pressure, 144.1±9.8 mm Hg systolic, 92.0±7.5 mm Hg diastolic) were randomized to double-blind placebo or to telmisartan 80 mg+modified release nifedipine 30 mg combination. Twenty-four-hour ambulatory blood pressure monitoring was performed off-treatment, after 6 weeks of treatment at sea level, on treatment during acute exposure to high altitude (3260 m) and immediately after return to sea level. Eighty-nine patients completed the study (age, 56.4±17.6 years; 52 men/37 women; body mass index, 28.2±3.5 kg/m 2). Twenty-four-hour systolic blood pressure increased at high altitude in both groups (placebo, 11.0±9 mm Hg; P<0.001 and active treatment, 8.1±10.4 mm Hg; P<0.001). Active treatment reduced 24-hour systolic blood pressure both at sea level and at high altitude (147.9±11.1 versus 132.6±12.4 mm Hg for placebo versus treated; P<0.001; 95% confidence interval of the difference 10.9-19.9 mm Hg) and was well tolerated. Similar results were obtained for diastolic, for daytime blood pressure, and for nighttime blood pressure. Treatment was well tolerated in all conditions. Our study demonstrates that (1) 24-hour blood pressure increases significantly during acute high-altitude exposure in hypertensive subjects and (2) treatment with angiotensin receptor blocker-calcium channel blocker combination is effective and safe in this condition.

Objective: Nocturnal periodic breathing occurs more frequently in men than in women with various clinical and pathophysiologic conditions. The mechanisms accounting for this sexrelated difference are not completely understood. Acetazolamide effectively counteracts nocturnal periodic breathing, but it has been investigated almost exclusively in men. Our aim was to explore possible determinants of nocturnal periodic breathing in a high-altitude setting both in men and in women. We hypothesized that increased hypoxic chemosensitivity in men could be associated with the development of nocturnal periodic breathing at altitude more frequently than in women, and that acetazolamide, by leftward shifting the CO2 ventilatory response, could improve nocturnal periodic breathing at altitude in a sex-independent manner. Methods: Forty-four healthy lowlanders (21 women), randomized to acetazolamide or placebo, underwent cardiorespiratory sleep studies at sea level offtreatment and under treatment on the first night after arrival at a 4,559-m altitude. Hypoxic and hypercapnic chemosensitivities were assessed at sea level. Results: Men, more frequently than women, exhibited increased hypoxic chemosensitivity and displayed nocturnal periodic breathing at altitude. Acetazolamide leftward shifted the CO2 set point and, at altitude, improved oxygenation and reduced periodic breathing in both sexes, but to a larger extent in men. Hypoxic chemosensitivity directly correlated with the number of apneas/hypopneas at altitude in the placebo group but not in the acetazolamide group. Conclusions: The greater severity of periodic breathing during sleep displayed by men at altitude could be attributed to their increased hypoxic chemosensitivity. Acetazolamide counteracted the occurrence of periodic breathing at altitude in both sexes, modifying the apneic threshold and improving oxygenation. Trial Registry: EU Clinical Trials Register, EudraCT; No.: 2010-019986-27; URL: https://www.clinicaltrial