Search Results (382)

Background: Congested tournament schedules impose substantial physiological stress in team sports; however, the integrated endocrine and inflammatory responses to real competitive match load in female handball players remain insufficiently characterized. Objective: This study aimed to characterize the acute biochemical responses, including hormonal, inflammatory, muscle damage, and bone metabolism markers, elicited by competitive tournament load in female handball players and to provide practical insights for optimizing recovery strategies and load management during short-term competitive periods. Methods: In a pre–post study design, venous blood samples were collected from competitive female athletes (n = 8; age 20.83 ± 2.93 years) before the first match and after the fourth consecutive match of an official university qualification tournament. Biochemical analyses included cortisol, insulin, IL-6, creatine kinase (CK), IGF-1, irisin, lactate dehydrogenase (LDH), osteocalcin, and testosterone. Pre-to-post changes were assessed using paired t-tests and effect sizes. Results: Tournament load induced substantial multisystem physiological perturbations. Significant increases were observed in cortisol (p < 0.001), insulin (p = 0.044), IL-6 (p < 0.001), CK (p < 0.001), and osteocalcin (p = 0.005), indicating activation of the hypothalamic–pituitary–adrenal axis, systemic inflammation, muscle membrane disruption, and enhanced bone turnover. Conversely, IGF-1 (p < 0.001) and testosterone (p = 0.004) significantly decreased, reflecting suppression of anabolic signaling and a shift toward a catabolic hormonal environment under cumulative match stress. LDH significantly decreased (p = 0.002), while irisin showed no significant change (p > 0.05). Conclusions: These findings demonstrate that congested tournament schedules provoke an integrated endocrine–inflammatory stress response in female handball players. Importantly, the observed anabolic–catabolic imbalance highlights the need for individualized recovery strategies, optimized load management, and adequate recovery periods to mitigate maladaptation and reduce injury risk during short-term competitive tournaments. Full article

Background: Societal stigma toward eating disorders and obesity remains pervasive and is associated with psychological distress, maladaptive eating behaviors, reduced help-seeking, and barriers to care. Despite its documented impact, comprehensive and psychometrically robust instruments to assess stigma—particularly in Spanish-speaking populations—are scarce. This study aimed to develop and validate a multidimensional measure of societal stigma toward eating disorders and obesity in Spain, grounded in contemporary stigma frameworks. Methods: A cross-sectional observational study was conducted in a large community sample recruited online (N = 2121). An initial pool of stigma-related items was developed based on theoretical and empirical literature and refined through expert content validation. Psychometric evaluation included item screening, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), bifactor modeling, and reliability assessment. The sample was randomly split for EFA (n = 988) and CFA (n = 658). Associations between stigma scores and sociodemographic and experiential variables were examined. Results: The final 36-item instrument demonstrated excellent psychometric properties. Bifactor analyses supported an essentially unidimensional structure dominated by a strong general stigma factor, with secondary content-specific dimensions (e.g., legitimacy, personal responsibility, visibility, and treatment beliefs). The theory-driven bifactor model showed excellent fit (CFI = 0.991; TLI = 0.990; RMSEA = 0.024). The general factor exhibited high reliability (ωₕ = 0.87). Higher stigma was observed among men, older participants, and individuals without personal or familial experience of eating disorders or obesity. Conclusions: This study provides a reliable and theoretically grounded instrument for assessing societal stigma toward eating disorders and obesity in Spain. The scale enables systematic research on stigma and offers a valuable tool for public health surveillance, intervention development, and evaluation of anti-stigma initiatives aimed at promoting compassionate and equitable care. Full article

Vein graft disease remains a significant limitation to the long-term patency of venous conduits following coronary artery bypass grafting. Early oxidative stress, triggered by ischaemia–reperfusion injury and haemodynamic changes following the implantation of veins into the arterial circulation, disrupts endothelial integrity and initiates inflammation, apoptosis, and maladaptive remodelling. The KEAP1-NRF2 axis is a central regulator of cellular antioxidant responses; however, its role in the development of vein graft disease remains poorly defined. This narrative review aimed to summarise what is known about NRF2/KEAP1 signalling in modulating vein graft pathology. Methods: A systematic search of PubMed was conducted to identify original research studies examining the NRF2/KEAP1 pathway in human saphenous vein tissue in vivo or ex vivo. Narrative synthesis was performed due to limited evidential availability and study heterogeneity. Results: Only one study has directly evaluated NRF2 pathway activation directly in human saphenous vein tissue, and it demonstrated that Protandim (a herbal dietary supplement) treatment increased antioxidant enzyme activity and reduced oxidative stress markers, including superoxide and 4-hydroxynonenal, both known activators of MAPK-dependent smooth muscle proliferation. Adjacent studies in other cells and tissues reveal that NRF2 intersects with multiple pathways central to vein graft pathology: it suppresses NFκB-mediated inflammation, modulates eNOS-NO signalling, inhibits NADPH oxidase expression, regulates MAPK activation, and influences angiogenic responses. However, context-dependent activation of NRF2 under arterial cyclic stretch can paradoxically drive proliferation through p62-mediated KEAP1 sequestration and enhanced glutathione synthesis. Conclusions: The NRF2/KEAP1 pathway serves as a central integrator of oxidative stress responses that directly intersect with established mechanisms of intimal hyperplasia and pathological angiogenesis. Post-translational KEAP1 inhibition may offer a targeted intervention point to limit these processes. Critical gaps remain regarding our understanding of the role of NRF2 in human saphenous vein under physiological arterial conditions and sex-specific pathway regulation. Mechanistic studies in vein-specific models are essential for advancing our understanding and any potential therapeutic translation. Full article

Right ventricular pressure overloading [RVPO] with secondary maladaptive RV remodeling and progressive myocardial dysfunction in patients with pulmonary hypertension associated with left-sided heart diseases [PH-LHDs] and in those with pulmonary arterial hypertension [PAH] still remains one of the most complex challenges in cardio-pulmonary medicine. Despite the advances in the optimization of diagnostic tools and the expansion of treatment options, there is still a great need for further research to gain a better understanding of the major pathophysiological mechanisms involved in both the RV responses to PO and to find new possibilities to stop the progression of the alterations inside the pulmonary arterial circulation [PAC]. This article summarizes current knowledge about the particularities of the RV structural and functional responses to abnormal PO and also provides an overview of the benefits and limitations of the currently available tools for clinical evaluations of the RV adaptability to high afterload. A major focus of this review relates to the possibilities for obtaining evidence about the existence of a still remaining adaptability to a normal afterload in an over-burdened RV, in case of abolition of the pathological PO and, in this regard, to also evaluate the clinical usefulness of the RV adaptability estimation for certain critical therapeutic decisions. Among the most important conclusions of this updated overview are: 1. Whereas single parameters are insufficiently reliable for the evaluation of RV dysfunction and for predictions of its prognostic relevance across the whole spectrum of RVPO, properly selected and integrated multiparametric approaches had meanwhile unequivocally proved that they can usually become sufficiently reliable. 2. Multiparametric approaches can substantially improve the prediction of a preserved RV responsiveness to the abolition of its steady PO by reversal of RV maladaptive remodeling and by the normalization of RV pump function. Such a prediction, which can be decisive for therapeutic decision-making especially in candidates for ventricular assist device [LVAD] implantation or thoracic organ transplantation, can have a crucial impact on patient survival. 3. The complex and temporally highly variable interactions between certain structural and functional changes in both the PAC and in the hemodynamic overloaded right-sided heart, as well as between the two ventricles, can often hamper the interpretation of certain changes in the measured parameters and even relevantly alter their reliability. Additionally, the progressive aggravation of a secondary tricuspid regurgitation [TR] has a particularly high negative (often also misleading) impact on the diagnostic and prognostic relevance of RVPO evaluations. Full article

Reactive oxygen species (ROS) and reactive nitrogen species (RNS) are central regulators of monocyte and macrophage biology, shaping their survival, differentiation, migration, and effector functions. In monocytes and macrophages, ROS and RNS arise from endogenous sources, such as mitochondria, NADPH oxidases, and myeloperoxidase, and from exogenous stimuli including pathogens, damaged tissues, and environmental oxidants. These reactive intermediates converge on redox-sensitive pathways such as NF-κB, Nrf2/HO-1, mitochondrial ROS signalling, and the NLRP3 inflammasome, thereby integrating metabolic stress with inflammatory activation. Redox balance is a key determinant of macrophage polarization: heightened ROS and RNS production drives pro-inflammatory M1 programs, whereas tightly regulated oxidative signalling supports M2 phenotypes associated with tissue repair and resolution. In chronic inflammatory disorders, notably atherosclerosis, oxidative stress amplifies monocyte recruitment, foam-cell formation, plaque instability, and maladaptive immunometabolic responses. The aim of this review is to recapitulate the major sources and functions of ROS and RNS in monocytes and macrophages and to synthesize current evidence on how these pathways collectively maintain or disrupt immune homeostasis. We further highlight emerging therapeutic strategies, such as NOX inhibitors, mitochondrial-targeted antioxidants, and Nrf2 activators, that seek to restore redox balance and offer promising avenues for the treatment of cardiovascular and immune-mediated diseases. Full article

Background: Recent advancements in heart failure (HF) therapy have significantly enhanced the management of patients across all phenotypes of left ventricular ejection fraction. However, these multidrug regimens frequently induce alterations in renal function by influencing intrarenal hemodynamics, thereby modifying glomerular capillary pressure. This phenomenon could result in a mild to moderate decline in estimated glomerular filtration rate (eGFR), often classified as “worsening kidney function.” This nomenclature stems from consistent observations of eGFR reductions recorded during HF treatment in clinical trials. This narrative review aims to elucidate why the observed eGFR declines in clinical practice may represent either loss of functioning glomeruli or pharmacologically mediated reductions in intraglomerular pressure that ultimately safeguards long-term renal and cardiovascular outcomes. Methods: By a comprehensive re-examination of data from HF clinical trials conducted with various classes of medications, all affecting eGFR, we sought to provide evidence that the decline in eGFR is associated with the activation of specific mechanisms that collectively contribute to a reduction in glomerular filtration pressure, a prominent factor in maladaptive neurohormonal responses. Results: From the investigation of angiotensin-converting enzyme inhibitors to the more recent non-steroidal mineralocorticoid receptor antagonist, the renal effects of these therapeutic regimens correlate with improvements in patient outcomes. The data consistently indicate that an early decline in eGFR, when coupled with an enhancement in HF outcomes, is associated with a more gradual decline in eGFR during long-term follow-up. Conclusions: Clinicians should recognize early declines in eGFR as indicators of favorable intraglomerular hemodynamic adjustments that mitigate maladaptive neurohormonal responses and contribute to improved long-term outcomes in patients with HF. Full article

Diabetic cardiomyopathy (DbCM) is an important contributor to heart failure (HF) in diabetes, occurring independently of other cardiovascular risk factors. Accumulating evidence demonstrates that cardiac lipotoxicity is a key driver of the onset and progression of DbCM and HF. Myocardial lipid homeostasis is coordinated by multiple transcriptional regulations, signaling pathway activation, and endoplasmic reticulum-mediated management involved in lipid metabolism. In DbCM, unbalanced fatty acid (FA) influx, handling, storage, and utilization initiates lipid overload, accumulation of toxic lipid intermediates (e.g., diacylglycerols and ceramides), and activation of maladaptive response. Notably, these lipid intermediates amplify reactive oxygen species (ROS) generation, which serves as a critical link between lipotoxic signaling and mitochondrial dysfunction by promoting electron leak, mitochondrial damage, and activation of inflammatory and cell-death pathways. These processes converge on adverse remodeling and contractile impairment, accelerating DbCM progression. This review integrates mechanistic and translational evidence linking dysregulated lipid handling to DbCM and discusses the potential therapeutic strategies that target lipid abnormalities. Full article

The transcriptomic effects of hybridization and triploidization were investigated in diploid and triploid rainbow trout, diploid brook trout, as well as triploid hybrids of rainbow trout and brook trout. The examined fish were reared under identical conditions for about two and a half years after hatching. Expression of ten genes involved in cellular respiration (Atp5bp, Slc25a5), mitochondrial functioning (Mrpl28, Micu2), ribosome biogenesis (Rpl24, Rps24), proteasome-mediated protein turnover (Derl1, Psmc2), and protein chaperoning (Hsp90B1, Pdia4) was studied in liver and muscle tissues. Most of the analyzed genes (Atp5bp, Slc25a5, Mrpl28, Micu2, Rpl24, Rps24, Derl1, and Psmc2) displayed comparable expression levels in the liver tissue across the examined triploid hybrids and diploid parental species, with stabilization of genes that were both positively and negatively compensated in the triploid rainbow trout. In turn, significant upregulation of Slc25a5, Derl1, Rps24, and Rpl24 genes, together with downregulation of Micu2 gene, was observed in the triploid rainbow trout liver and muscle, respectively. On the other hand, triploid hybrids showed marked transcriptional upregulation of genes primarily associated with energy metabolism and protein synthesis (Atp5pb, Slc25a5, Rpl24, Rps24, and Pdia4) relative to all the fish groups examined. Although protein-synthesis- and energy-related genes were upregulated in the muscles of triploid hybrids, the recorded growth performance data did not indicate clear evidence of growth heterosis (MPH = −14.3% for body weight; MPH = −0.4% for body length), suggesting that potential benefits of increased heterozygosity in this cross may not be fully reflected in enhanced growth. Three- to four-fold downregulation of the heat shock protein (Hsp90B1) gene was also observed in both tissues of triploid hybrids compared with purebred diploid and triploid trout, which may reflect potential maladaptive genomic effects commonly observed in distant salmonid crosses, suggesting altered stress-response regulation in the examined triploid hybrids. Full article

Background: Contemporary models of parental burnout conceptualize it as an interplay between parental demands and insufficient resources. However, research and current models remain sparse in their understanding of these demands and dynamics within the context of managing a child’s sleep wellness and related problems, which constitute a fundamental aspect in early parenting. The present work addresses this gap by examining this issue comprehensively. Methods: 2291 mother–child dyads were recruited from two sources: a random population sample (n = 1409) and a clinical sample (n = 882) of mothers seeking consultation for their child’s sleep issues (0–5 years old). Mothers completed an extensive panel of validated instruments and survey questions covering burnout and psychopathologies, sleep parameters, psychosocial, organizational, and demographic variables. Inferential analyses, regression modeling, cluster analysis, and mediation models were applied. Results: Two distinct profiles of parental burnout emerged: one associated with child sleep disturbances and the other with general parenting stress. The strongest-weighted risk factors pertained to maladaptive beliefs and perceptions (e.g., shame, “I am a bad parent”, “My child cries because I do not meet his needs”), as well as additive stressors such as interparental tension and daytime child behavioral problems. The strongest protective factors involved resources that reduced parental demands or facilitated recovery, including couple satisfaction, a consistent bedtime routine, greater capacity to take breaks (e.g., additional caregivers, father nighttime involvement, parental cohabitation, and child screen time). Conclusion: The identification of two distinct burnout profiles highlights the importance of incorporating, or placing more centrally, the management of young children’s insomnia in contemporary theoretical models of parental burnout. This research highlights the need for interventions on healthy self-beliefs and perceptions, effective daytime parenting strategies, positive couple dynamics, consistency in bedtime routines, and equitable distribution of caregiving responsibilities between parents to reduce the risk of parental burnout. Full article

Background: Eating disorders (EDs) frequently co-occur with trauma-related symptoms and elevated autistic traits (ATs), both of which contribute to clinical complexity. Social camouflaging, strategies used to mask or compensate for ATs, has been increasingly described in ED populations, yet its relationship with trauma-related symptoms remains poorly understood. This study aimed to examine the association between social camouflaging and post-traumatic stress symptoms in individuals with EDs and to evaluate whether trauma-related symptomatology is associated with camouflaging behaviors. Methods: A total of 67 ED patients were assessed using the Adult Autism Subthreshold Spectrum, the Trauma and Loss Spectrum—Self Report (TALS-SR), the Camouflaging Autistic Traits questionnaire (CAT-Q), and the Eating Disorder Inventory (EDI-2). Participants were divided into high-trauma-symptoms (HTS) (N = 36, 53.7%) and low-trauma-symptoms (LTS) (N = 31; 46.3%) groups based on TALS-SR criteria. Results: The sample was predominantly female (92.5%), and gender distribution differed between groups, which may represent a potential confounding factor and limits the generalizability of the findings. The HTS group reported significantly higher TALS-SR, EDI-2, CAT-Q, and AdAS Spectrum scores, although for the latter the p-value was barely significant (p = 0.046). No differences emerged in the distribution of ED diagnoses between groups. CAT-Q scores were significantly positively correlated with TALS-SR total scores and with domains related to reaction to losses, maladaptive coping, avoidance/numbing, and personal vulnerability. Regression analyses showed that overall trauma-related symptoms were significantly associated with greater camouflaging; however, the proportion of explained variance was modest, suggesting that trauma-related symptoms represent only one of multiple factors linked to camouflaging. Conclusions: Among individuals with EDs, higher trauma-related symptomatology is linked to greater use of social camouflaging strategies. These findings suggest that camouflaging may represent a transdiagnostic correlate connecting neurodevelopmental vulnerability and trauma responses within ED populations, underscoring the importance of integrated assessment and trauma-informed care. Full article

Autophagy is increasingly recognized as a context-dependent regulatory process that links cellular quality control with systemic metabolic and neurological homeostasis. However, how distinct autophagy pathways contribute to disease progression, and how they are dynamically modulated by host–microbiota interactions, remain incompletely understood. In this review, we synthesize recent advances in the molecular regulation of macroautophagy, microautophagy, and chaperone-mediated autophagy (CMA), with a particular emphasis on selective autophagy and its disease-specific functions. We examine emerging evidence implicating autophagy as a bidirectional modulator in neurodegenerative and metabolic disorders, highlighting conditions under which autophagy exerts protective versus maladaptive effects. Importantly, we integrate recent findings on the microbiota–gut–brain axis to illustrate how microbial signals reshape autophagic responses and influence disease susceptibility and progression. Finally, we summarize current progress and limitations in autophagy-targeted therapeutic strategies, including nanomedicine-based delivery systems, and propose conceptual frameworks to guide the development of precise, context-aware autophagy interventions. This review provides an updated and integrative perspective that bridges molecular mechanisms, host–microbiota crosstalk, and translational opportunities in autophagy-related diseases. Full article

Diabetic kidney disease (DKD) is a major complication of diabetes mellitus that contributes substantially to chronic kidney failure and increased cardiovascular risk. Beyond progressive deterioration of renal function, DKD is associated with disturbances in endocrine and vascular regulation. Among these, alterations in vitamin D homeostasis and blood pressure (BP) control represent clinically relevant, yet incompletely integrated aspects of DKD pathophysiology. This narrative review synthesizes current evidence on the multidirectional relationships between DKD, vitamin D deficiency, and arterial hypertension (AH). Attention is given to renal mechanisms responsible for reduced vitamin D availability in DKD, including proteinuria-related loss of vitamin D-binding proteins, impaired proximal tubular reabsorption, decreased renal activation of vitamin D, and hormonal regulators such as fibroblast growth factor-23. It further discusses how insufficient vitamin D signaling may influence renal and vascular pathways involved in BP regulation. Mechanistic links between vitamin D deficiency and AH in DKD are discussed, with emphasis on maladaptive activation of the renin–angiotensin–aldosterone system (RAAS), persistent inflammation, oxidative stress, endothelial dysfunction, and insulin resistance. These interdependent processes promote both renal injury progression and sustained elevations in BP, forming a self-reinforcing pathogenic loop. Finally, available data on vitamin D-based therapeutic strategies in DKD are reviewed, including native vitamin D supplementation, active vitamin D metabolites, and vitamin D receptor agonists. Although experimental and observational studies suggest potential nephroprotective and vasculoprotective effects, evidence from randomized clinical trials remains heterogeneous. Further well-designed prospective studies are required to clarify the clinical utility of vitamin D interventions in patients with DKD and coexisting AH. Full article

The deterioration of water quality is associated with an increased disease risk, although the exact mechanism remains unclear. This study investigated the infection dynamics of cyprinid herpesvirus 2 (CyHV-2) in crucian carp (Carassius auratus gibelio) subjected to varying nitrite stress levels. A control group and three CyHV-2-infected groups exposed to nitrite concentrations of 0, 5, and 10 mg/L were set up. Results indicated that nitrite exposure caused a dose-dependent reduction in survival rates and decreased viral loads in the spleens of surviving fish. Nitrite stress elevated malondialdehyde (MDA) levels and glutathione peroxidase (GPx) activity, while reducing superoxide dismutase (SOD) and catalase (CAT) activities in the liver. Hepatic cytokine analysis revealed early peaks in tumor necrosis factor α (TNF-α) and interleukin 1β (IL-1β), alongside delayed response of interferon γ (IFN-γ) and interleukin 10 (IL-10), indicating impaired anti-inflammatory regulation. In the kidney, nitrite stress amplified immune gene expression, characterized by the upregulation of tlr5 (Toll-like receptor 5) and nf-κb (nuclear factor κB) and the inhibition of iκκβ (inhibitor of NF-κB kinase subunit β), leading to prolonged NF-κB signaling. This was associated with a marked upregulation of il-1β and il-8 (interleukin 8), alongside a delayed ifn-γ response. The combination of nitrite stress and CyHV-2 infection exacerbated oxidative damage and triggered a maladaptive immune response, thereby accelerating disease progression. Full article

During ischemia, endothelial cell integrity is compromised, as a consequence, blood barrier homeostasis is disrupted. Therefore, the structural and functional preservation of endothelial cells is paramount when trying to improve outcomes after ischemic injury. Endoplasmic reticulum (ER) stress is increasingly recognized as a key player in ischemic injury through unfolded protein response (UPR) signalling, and its crosstalk with mitochondrial death pathways. This study provides a cost-effective and straightforward method to delve into the relationship between ER stress and ischemia in human microvascular endothelial cells-1 (HMEC-1). HMEC-1 was exposed to 8 h of oxygen–glucose deprivation (OGD) in glucose-free medium with rapidly induced hypoxia. Hypoxia, oxygen consumption, cell viability, apoptosis, and ER stress markers (BiP/GRP78, PERK, ATF6, IRE1/XBP1s, CHOP) were assessed by RT-qPCR and Western blot. Cell viability decreased by approximately 33% following OGD, while CHOP expression increased ~4-fold, indicating significant ER stress induction. The model enables quantification of metabolic stress (OCR), as well as evaluation of viability loss, membrane integrity, apoptotic commitment, and discrimination between ER stress resolution versus maladaptation. Overall, GasPak EZ Pouch Systems provide a reproducible and practical in vitro platform to study ischemic injury down to the mechanistic details of ER-mitochondria signalling. They give the opportunity to evaluate therapeutic approaches that target ER homeostasis to limit apoptosis and/or recovery of metabolic function after ischemia. This method could allow rapid screening of ER stress-modulating interventions aimed at preserving endothelial barrier function, in various ischemic contexts. Full article

Heart failure (HF) remains a leading cause of morbidity and mortality worldwide and is driven by complex, interconnected pathophysiological processes, including maladaptive cardiac remodeling, fibrosis, hypertrophy, metabolic dysregulation, and cardiomyocyte loss. MicroRNAs (miRNAs), small non-coding RNAs that act as key post-transcriptional regulators of gene expression, have emerged as important coordinators of these processes across cardiomyocytes and non-myocyte cardiac cell populations. In addition to altered expression patterns, accumulating evidence indicates that miRNA activity is dynamically influenced by regulated biogenesis, maturation, and context-dependent mechanisms of action. Through reversible translational repression and longer-term mRNA destabilization, miRNAs support adaptive responses to acute cardiac stress, whereas their persistent dysregulation contributes to remodeling pathways that promote HF progression. This comprehensive narrative review provides an integrative overview of current knowledge on the role of miRNA networks in shaping the molecular heterogeneity of heart failure across disease stages, phenotypes, and cardiac cell types. Drawing on a broad body of experimental and clinical literature, we discuss advances in understanding miRNA biogenesis, post-transcriptional control, and cell-specific effects, while highlighting conceptual developments rather than applying systematic selection criteria. We further examine the translational and clinical implications of miRNA biology, critically considering the progress of miRNA-based therapeutics alongside the biological and practical challenges that continue to limit their widespread clinical implementation. In parallel, we explore the emerging potential of circulating miRNAs as minimally invasive biomarkers that reflect upstream regulatory stress at the level of RNA processing and post-transcriptional regulation. Finally, we address the growing application of artificial intelligence and machine learning approaches to high-dimensional miRNA datasets, which enable integrative analyses across clinical, imaging, and multi-omics domains and support biomarker discovery, patient stratification, and prediction of therapeutic response. Collectively, miRNA biology, supported by systems-level and AI-driven analytical frameworks, offers a unifying perspective for understanding, classifying, and monitoring cardiac remodeling in heart failure. Full article