INTRODUÇÃO: A fadiga é freqüente em pessoas com insuficiência cardíaca e limita a manutenção de um estilo de vida compatível com senso desejável de autonomia e independência. O controle das limitações funcionais é prioridade no cuidado à pessoa com insuficiência cardíaca, mas não há estudos sobre fadiga em amostras de pacientes brasileiros. OBJETIVO: Caracterizar a fadiga em pacientes com insuficiência cardíaca e comparar sua freqüência e intensidade com voluntários sem doença. MÉTODO: Estudo descritivo-exploratório, com 300 pacientes ambulatoriais. (masculino=68,3%, idade média de 54,8(±11,5) anos, escolaridade média de 6,0(±4,1) anos; Classe Funcional I= 44,7%) e 64 voluntários sem doença, acompanhantes de pacientes ambulatoriais (masculino=34,4%, idade média de 33,3(±10,7) anos, escolaridade média de 10,2(±3,2) anos). Foi aplicado instrumento com as escalas de fadiga (Dutch Fatigue Scale - DUFS) de fadiga ao esforço (Dutch Exertion Fatigue Scale - DEFS), o Inventário de Depressão de Beck (IDB), instrumento de avaliação da atividade física (International Physical Activity Questionnaire) e itens para avaliação da dispnéia, tabagismo e terapia medicamentosa. As escalas DUFS e DEFS foram adaptadas para o Brasil e mostraram propriedades psicométricas adequadas (consistência interna, pelo alfa de Cronbach, na DUFS=0,848 e na DEFS=0,922 e solução fatorial que reproduziu suas estruturas originais). O IDB mostrou consistência interna adequada (alfa de Cronbach=0,873). Testes não paramétricos foram aplicados para analisar a associação entre fadiga e fadiga ao esforço (intensidade de fadiga - escore total DUFS; intensidade de fadiga ao esforço - escore total DEFS; freqüência de fadiga substancial - DUFS >=14,5; freqüência de fadiga substancial ao esforço - DEFS>=12,5) com variáveis selecionadas. RESULTADOS: O escore total médio da DUFS nos pacientes (19,4±8,2) foi mais elevado que o dos voluntários (16,8±6,1) (p=0,042); o mesmo ocorreu com a DEFS (pacientes=19,3±3,9; voluntários=12,6±3,9) (p<0,0001). A freqüência de DUFS>=14,5 foi semelhante entre os pacientes e voluntários (p=0,225) e da DEFS>=12,5 foi mais alta entre os pacientes que nos voluntários (p<0,0001). Nos pacientes observou-se maior intensidade de fadiga nas mulheres (p=0,014); na presença de dispnéia (p=0,000); uso de digitálicos (p=0,020); classes funcionais mais elevadas (p=0,000); nos sedentários (p=0,007), entre os com escores de depressão mais elevados (p=0,000) e com distúrbios do sono (p=0,000). A fadiga ao esforço foi mais elevada nos pacientes com dispnéia (p=0,000); que usavam digitálicos (p=0,021); em classe funcional mais elevada (p=0,000); sedentários (p=0,000); com escores de depressão mais elevados (p=0,000) e com distúrbio do sono (p=0,0001). A freqüência de DUFS>=14,5 foi mais elevada naqueles com dispnéia (p<0,0001); uso de betabloqueador (p=0,032); classe funcional mais elevada (p<0,0001); escores de depressão mais elevados (p<0,0001) e naqueles com distúrbio do sono (p<0,0001). Freqüências da DEFS>=12,5 foram mais elevadas na dispnéia (p<0,0001); classe funcional mais elevada (p<0,0001); nos sedentários (p=0,007); escores mais elevados de depressão (p<0,0001) e naqueles com distúrbio do sono (p<0,0001). Não se associaram com qualquer variável de fadiga as seguintes variáveis: índice de massa corporal, uso de inibidor de enzima conversora de angiotensina, idade e tabagismo. DISCUSSÃO: Esses resultados contribuem para o conhecimento sobre sintoma relevante para qualidade de vida e para o cuidado do paciente com insuficiência cardíaca / INTRODUCTION: Fatigue is a frequent symptom in heart failure patients that limits maintaining a life style compatible with a desirable sense of autonomy and independence. Although controlling functional limitations is a priority care goal of heart failure patients there are no studies on fatigue with Brazilian patient samples. OBJECTIVE: To characterize fatigue in heart failure patients and to compare their fatigue frequency and intensity with volunteers without heart failure. METHODS: Descriptive-exploratory study with 300 outpatients (male=68.3%, mean age=54.8(±11,5) years; mean schooling=6,0(±4,1) years; functional class I of heart failure = 44,7%), and 64 volunteers without heart failure, outpatients accompanying (male=34.4%, mean age=33.3(±10.7) years, mean schooling=10.2(±3.2) years). It was applied an instrument with fatigue (Dutch Fatigue Scale - DUFS) and exertion fatigue escales (Dutch Exertion Fatigue Scale - DEFS), Beck Depression Inventory (IDB), International Physical Activity Questionnaire and items to assess dyspnea, smoking and pharmacological treatment. DUFS and DEFS were adapted to Brazilian samples and their psychometric properties were adequate (Cronbach\'s alpha: DUFS=.848; DEFS=.922, and reproduction of the original structure by factor analysis). BDI presented good internal consistency (Cronbach\'s alpha=.873). Non-parametric tests were applied to test associations of fatigue, exertion fatigue (fatigue intensity - DUFS total score; exertion fatigue intensity - DEFS total score; frequency of substantial fatigue - DUFS >=14,5; frequency of substantial exertion fatigue - DEFS>=12,5). RESULTS: Patients mean DUFS total score (19.4±8.2) was higher than volunteers (16.8±6.1) (p=.042); the same occurred with DEFS (patients=19.3±3.9; volunteers=12.6±3.9) (p<.0001). The frequency of DUFS>=14,5 was not different between patients and volunteers (p=.225); frequency of DEFS>=12,5 was higher for patients than volunteers (p<.0001). In the patients group, fatigue intensity was higher for women (p=.014); and also in presence of dyspnea (p=.000); digoxin use (p=0,020); higher functional classes (p=.000); in sedentary patients (p=.007), higher IDB scores (p=.000), and sleep disturbance (p=.000). Exertion fatigue was higher in patients with dyspnea (p=.000); using digoxin (p=.021); in higher functional classes (p=.000); sedentary (p=.000); higher IDB scores (p=.000) and sleep disturbance (p=.0001). Frequency of DUFS>=14,5 was higher in patients with dyspnea (p<.0001); using betablockers (p=.032); higher functional classes (p<.0001); higher IDB scores (p<.0001) and sleep disturbance (p<.0001). Frequency of DEFS>=12,5 was higher in presence of dyspnea (p<.0001); higher functional classes (p<.0001); sedentary patients (p=.007); higher BDI scores (p<.0001) and sleep disturbance (p<.0001). There were no associations of fatigue variables with body mass index, users of angiotensin receptor blockers, age and smoking. DISCUSSION: This study results contribute to the knowledge concerning to a symptom relevant to the quality of life and nursing care of heart failure patients

Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-02-24T16:18:57Z No. of bitstreams: 2 Dissertação - Silene Jacinto da Silva - 2012.pdf: 1244943 bytes, checksum: 169827dfbf3ff42a25f37a6dbdd252f2 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-02-24T16:21:26Z (GMT) No. of bitstreams: 2 Dissertação - Silene Jacinto da Silva - 2012.pdf: 1244943 bytes, checksum: 169827dfbf3ff42a25f37a6dbdd252f2 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-02-24T16:21:26Z (GMT). No. of bitstreams: 2 Dissertação - Silene Jacinto da Silva - 2012.pdf: 1244943 bytes, checksum: 169827dfbf3ff42a25f37a6dbdd252f2 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2012-04-23 / The Deletion/Insertion polymorphisms of the angiotensin converting enzyme genes and the A1166C of the angiotensin II receptor AT1R were analyzed in a cohort of 90 patients, among 30 carriers of chronic heart failure, aging from 30 to 86, in which 66, 6% were males. The control group was based on 60 cardiopathic patients without heart failure matched by age and gender. The heart failure was attributed to the etiologies: chagas cardiomyopathy (46,7%), idiopathic dilated cardiomyopathy and others (23,3%), hypertensive cardiomyopathy (20%) and ischemic cardiomyopathy (10%). In order to determine the genotypes the PCR - RFLP (Polymerase Chain Reaction - Restriction Fragment Length Polymorphism) technique was applied. The genotypes distribution was analyzed, as well as the allele’s frequency and the possible polymorphisms associations with different clinical variations and heart failure carrier’s evolution during 12 months. For the analysis of descriptive and inferential statistical were used the t test, chi-square (χ2) test, Kaplan - Meier and ANOVA. The distribution of the genotypes D/I of the genes ACE and the polymorphisms A1166C of the angiotensin II was similar between the two groups (p = 0,23 e p= 0,12). The evaluation of the polymorphisms studies presented a lack of association with the clinical variations analyzed and the evolution of the heart failure carriers during 12 months. / Os polimorfismos de Deleção/Inserção do gene da enzima conversora da angiotensina e A1166C do receptor AT1R da angiotensina II foram estudados em uma coorte com 90 pacientes, sendo 30 portadores de insuficiência cardíaca crônica, com idades variando entre 30 e 86 anos, dos quais 66,6% eram do sexo masculino. O grupo controle foi constituído por 60 pacientes cardiopatas, porém sem insuficiência cardíaca, pareados por idade e sexo. A insuficiência cardíaca foi atribuída às seguintes etiologias: cardiomiopatia chagásica (46,7%), cardiomiopatia dilatada idiopática e outras (23,3%), cardiomiopatia hipertensiva (20%) e cardiomiopatia isquêmica (10%). A determinação dos genótipos foi realizada pelas técnicas PCR - RFLP (Polymerase Chain Reaction - Restriction Fragment Length Polymorphism). Foram avaliadas as distribuições dos genótipos, as frequências alélicas, as prováveis associações dos polimorfismos com diferentes variáveis clínicas e a evolução dos portadores de insuficiência cardíaca no seguimento de 12 meses. Para a análise da estatística descritiva e inferencial utilizou-se o teste t, teste Qui-quadrado (χ2), kaplan - Meier e ANOVA. A distribuição dos genótipos D/I do gene ECA e do polimorfismo A1166C foi semelhante entre os dois grupos (p=0,23 e p=0,12). A avaliação dos polimorfismos estudados apontou para a ausência de associação com as variáveis clínicas analisadas e com a evolução dos portadores de insuficiência cardíaca durante o seguimento de 12 meses.

O objetivo deste estudo foi avaliar o uso da cintilografia de perfusão miocárdica planar de repouso para o diagnóstico de insuficiência coronariana aguda em pacientes com dor torácica e eletrocardiograma sem alterações sugestivas de isquemia. Foram estudados 71 pacientes com idades entre 34 e 87 (média 58, desvio-padrão 12) anos; 44 (62%) eram do sexo masculino e 27 (38%) do feminino. Os pacientes com dor torácica foram avaliados na unidade de emergência com anamnese, exame físico e eletrocardroqrarna de 12 derivações. Pacientes com dor torácica de duração superior a 20 minutos, em vigência da dor ou sem dor, mas que sofreram dor torácica até seis horas anies do atendimento e com eletrocardioqrarna sem alterações sugestivas de isquemia miocárdica, foram submetidos à cintilografia planar de perfusão miocárdica de repouso quando solicitada pelo médico assistente. O tempo médio entre o início da dor toràcica e a Injeção do radiotraçador foi de três horas e seis minutos. Treze pacientes apresentavam dor torácica no momento da injeção. Foram colhidas amostras sanguineas para dosagens de atividade da creatinoquinase-MB (CK-MB), CK-MB massa, troponina I e mioglobina, seis horas após o início da dor torácica. O diagnóstico de insuficiência coronariana aguda foi feito em pacientes com angina de repouso, infarto agudo do miocárdio, pacientes submetidos à revascularização miocárdica, presença de lesões coronarianas significativas na angiografia (>- 70% estenose em artérias coronárias ou seus ramos ou .- 50% em tronco de artéria coronária esquerda) realizada durante a inernação e morte cardíaca foram considerados eventos cardíacos maiores. As cintilografias com defeito de captação foram consideradas sugestivas de isquemia miocárdica e foram comparadas com o diagnóstico clínico e com a ocorrência de eventos cardíacos maiores até três meses após a alta.Pacientes sem insuficiência coronariana aguda, dispensados da unidade de emergência, foram encaminhados para realização ambulatorial de cintilografia de perfusão miocárdica tomográfica de esforço ou com dipiridamol. Vinte e um pacientes (29,6%) tiveram o diagnóstico de insuficiência coronariana aguda e em 15 (21,1%) ocorreram eventos cardíacos maiores (oito com infarto agudo do miocárdio e sete foram submetidos à revascularização miocárdica). A cintilografia planar de perfusão miocárdica demonstrou defeitos de captação em 21 (29,6%) pacientes, dos quais 16 (76,2%) tiveram o diagnóstico de insuficiência coronariana aguda, 12 (80%) apresentaram eventos cardíacos maiores e 7 (87,5%) infarto agudo do miocárdio. O valor preditivo negativo da cintilografia planar de perfusão miocárdica foi de 90% para o diagnóstico de insuficiência coronariana aguda e de 94% para detecção de eventos cardíacos maiores. Portanto a cintilografia planar de perfusão miocárdica foi eficaz para o diagnóstico de insuficiência coronariana aguda em pacientes com dor torácica e electrocardiograma sem alterações sugestivas de isquemia / The objective of the study was to evaluate the usefulness of rest scintigraphic planar myocardial perfusion imaging in patients with acute chest pain suspected of myocardial ischemia and nondiagnostic ECG in the diagnosis of acute coronary syndromes and to predict adverse cardiac outcomes. Patients within 6 hours of chest pain onset and nondiagnostic ECGs underwent planar myocardial perfusion imaging with Technetium-99m sestamibi and measurements of serum creatine kinase-MB, creatine kinase-MB mass. troponin and myoglobin 6 hours after the onset of symptoms. Studies showing perfusion defects were considered suggestive of acute coronary syndromes and were compared to the diagnosis made by the attending cardiologist. Clinical diagnosis of acute coronary syndromes was made In patients with rest angina admitted to the hospital, acute myocardial Infarction, myocardial revascularization, demonstration of significant coronary artery disease on angiography or cardiac death. Acute myocardial revascularization and cardiac death were considered major cardiac events. Patients discharged without acute coronary syndromes were scheduled for outpatient stress myocardial perfusion imaging. A total of 71 patients underwent planar myocardial perfusion imaging. The mean age was 58 +- 12 years, 44 (62%) were male and 27 (38%) female. The mean time between chest pain onset and radiotracer injection was 3 hours and 6 minutes, thirteen patients had chest pain at the moment of iniection. Twenty-one (29,6%) patients had acute coronary syndromes, 15 (21,1 %) had major cardiac events (8 myocardial infarction and 7 underwent myocardial revascularization). Planar perfusion imaging demonstrated perfusion defects in 21 patients, 16 (76,2%) patients with acute coronary syndromes, 12 (80%) patients who had major cardiac events and in 7 (87,5%) patients with myocardial infarction. The negative predictive value of planar perfusion image was 90% for diagnosis of acute coronary syndromes and 94% for detecting major cardiac events. In conclusion, early planar perfusion imaging allowed for a rapid and accurate risk stratification of emergency departments patients with possible myocardial ischemia and nondiagnostic ECGs

Introdução: A cardiomiopatia dilatada é uma das principais causas de insuficiência cardíaca com alta morbidade e mortalidade. Alterações genéticas em mais de 29 genes já foram relacionadas com a doença, contudo, elas explicam apenas uma pequena porcentagem dos casos sugerindo haver então outros genes relacionados com a doença. Foram relacionados para o presente projeto quatro genes candidatos, previamente relacionados com outras doenças cardíacas, para verificação de uma possível associação com a cardiomiopatia dilata idiopática. Objetivos: Avaliar a presença e frequência de mutações nos genes ACTC1, CSRP3, FKBP1A e FKBP1B de pacientes com cardiomiopatia dilatada do Instituto do Coração de São Paulo (InCor, FMUSP), investigar se há correlações entre o genótipo e o fenótipo e estudar as alterações funcionais desencadeadas pelas mutações encontradas. Métodos: Amostras de DNA de 186 pacientes com cardiomiopatia dilatada idiopática foram selecionados de um banco de dados do Instituto do Coração e triados geneticamente para alterações nos genes selecionados. Resultados e Discussão: Foram encontradas nove novas variantes genéticas. Cinco delas também estavam presentes no grupo controle, sendo excluídas como causativas da doença. Três delas não estavam presentes no grupo controle, contudo, dados de bioinformática avaliaram as alterações com um risco baixo de serem causativas. Uma alteração no gene CSRP3, que levava a troca de aminoácido, não estava presente no grupo controle e apresentou dados indicativos de mutação causativa da doença. Lâminas cardíacas foram avaliadas para verificação de possíveis dos mecanismos de ação, contudo, houve apenas a exclusão de alguns mecanismos previamente descritos na literatura. Conclusões: Não há evidências de que as alterações nos genes ACTC1, FKBP1A e FKBP1B estariam associadas com o desenvolvimento da doença. A alteração no gene CSRP3 também é capaz de causar cardiomiopatia dilatada idiopática / Introduction: Dilated Cardiomyopathy is one of the leading causes of heart failure with high morbidity e mortality. Already known genetic alterations explain little percentage of cases suggesting that other genes would be related with the disease. Four candidates genes previously related with other cardiac diseases were selected for the project to verify a possible relationship with dilated cardiomyopathy. Objectives: Evaluate the presence and frequency of genetic alterations in ACTC1, FKBP1A, FKBP1B and CSRP3 genes in dilated cardiomyopathy patients of São Paulo Heart Institute (Incor, FMUSP). To investigate for genotype/phenotype correlations and to study functional alterations triggered by the found mutations. Methods: DNA samples from 186 patients with dilated cardiomyopathy were selected from the Incor DNA bank and genetically screened for alterations in the selected genes. Results and Discussion: Nine new genetic variants were found. Five of them were present in the control population, thus being excluded as disease causative. Three of them were not present in the control population; however, bioinformatics analysis evaluated the alterations having a low risk of being causatives. One alteration in CSRP3 gene that resulted in amino-acid change was not present in control population and exhibit indicative data of disease causing mutation. Analysis of patient heart showed no difference from some disease mechanisms described in literature. Conclusions: There are no evidences that alterations in ACTC1, FKBP1A and FKBP1B genes would associated with disease development. Alteration in CSRP3 gene is also capable to cause dilated cardiomyopathy s

L’insuffisance cardiaque est une pathologie chronique fréquente et grave, dont l’évolution est émaillée de décompensations qui nécessitent généralement une hospitalisation. Malgré des recommandations scientifiques claires (traitement de l’étiologie et des comorbidités, traitement symptomatique précoce des décompensations, traitement de fond pour les cas à fraction d’éjection diminuée), l’organisation du système de santé ne favorise pas la délivrance optimale des soins recommandés. On constate en effet dans la littérature que la délivrance des soins, ainsi que le contenu des soins délivrés, sont très variables d’un environnement à l’autre, avec un impact sur le risque de réhospitalisation. L’amélioration de la qualité des soins nécessite donc de pouvoir décrire les modalités de délivrance et le contenu des soins, c’est-à-dire le parcours de soins. Les méthodes de description de ces parcours sont rares et non consensuelles. L’objectif de cette thèse est de proposer des méthodes de description des parcours de soins, dans l’ambition de proposer des aides à la prise de décision en clinique et en santé publique. Deux études sont réalisées sur deux bases très différentes : une base de données médico-administrative ambulatoire et hospitalière à l’échelle d’une région, et une base de données clinique hospitalière monocentrique. Ces deux études mettent en évidence, à l’aide d’une classification ascendante hiérarchique sur composantes principales, des groupes de patients aisément interprétables. En particulier, elles montrent chacune deux groupes dont les caractéristiques cliniques sont proches, mais dont la prise en charge est très différente ; une prise en charge peu intense est associée à une évolution défavorable. La méthodologie utilisée dans ces études est discutée à la lumière de la littérature, et les opportunités offertes par les résultats en termes de recherche, de pratique clinique, et de santé publique, sont explorées. / Heart failure is a frequent and serious chronic pathology, whose evolution is peppered with decompensations that usually require hospitalization. Despite clear scientific recommendations (treatment of etiology and co-morbidities, early symptomatic treatment of decompensations, specific treatment for cases with decreased ejection fraction), the organization of the health system does not promote optimal delivery of recommended care. The literature reports that the delivery of care, as well as the content of delivered care, vary widely from one environment to another, with an impact on the risk of rehospitalization. Therefore, improving the quality of care needs to describe the delivery modalities and the content of care, that is to say, the care pathway. The methods of describing these pathways are rare and non-consensual. The aim of this thesis is to propose methods for describing care pathways, with the aim of offering support for clinical and public health decision-making. Two studies are carried out on two very different bases: an ambulatory and hospital medico-administrative database on a regional scale, and a monocentric clinical hospital database. These two studies highlight, using a hierarchical ascending classification on principal components, easily interpretable groups of patients. In particular, they each show two groups whose clinical characteristics are similar, but whose management is very different; a low level of care is associated with an poor prognosis. The methodology used in these studies is discussed in light of the literature, and the opportunities offered by the findings in terms of research, clinical practice, and public health are explored.

Aims: Thiazolidinediones have been advocated as second or third line insulin sensitizing agents in the management of type 2 diabetes (T2DM). Their widespread use has been hampered by concerns about their cardiovascular safety, including fluid retention. Metformin is established as first-line glucose-lowering pharmacotherapy in T2DM. It has also been suggested that it may have benefits in alleviating insulin resistance in type 1 diabetes (T1DM). This thesis examined: (i) cardiovascular, renal and metabolic differences between individuals with T2DM ‘tolerant’ or ‘intolerant’ of TZDs; (ii) risk factors for TZD-associated oedema in T2DM; and (iii) the potential for metformin as adjunct therapy in T1DM. Methods: (i) A small clinical study characterising TZD tolerant and intolerant individuals with T2DM; (ii) A population-based epidemiological study of TZD induced oedema in individuals with T2DM in Tayside, Scotland (using incident loop diuretic prescription as a surrogate); (iii) A systematic review and meta-analysis of published studies of adjunct metformin in T1DM. Results (i) During a five-day high sodium diet, two known TZD-intolerant individuals with T2DM had reductions in haematocrit, aldosterone, and diastolic BP and increases in ANP and central and peripheral augmentation indices which were outwith reference ranges derived from nine TZD-tolerant individuals; (ii) Predictors of time to loop diuretic prescription included age, body mass index, systolic BP, haematocrit, ALT and macrovascular disease but rates of this outcome did not differ by therapy: 4.3% (TZDs) vs 4.7% (other agents) [unadjusted OR 0.909 (95% CI 0.690, 1.196); p = 0.493]; (iii) In meta-analysis of nine small studies in T1DM (192.8 patient-years of follow-up), metformin was associated with a reduction in total daily insulin dose (6.6 units/day; p < 0.001) but no studies examined cardiovascular surrogates or outcomes. Conclusions: Hypotheses were generated for several potential biomarkers predictive of TZD-induced oedema but the clinical importance of TZDs as a risk factor for oedema in individuals with T2DM was questioned. As there is some evidence for the safety of metformin as an adjunct therapy in T1DM but little evidence of efficacy, larger studies are warranted.

Hjärtsvikt drabbar cirka två procent av befolkningen och sjukdomen påverkar personens vardag och förmåga till att utföra vardagliga sysslor. Prognosen för hjärtsvikt är allvarlig, personer som blivit diagnostiserade med hjärtsvikt har en median överlevnadstid på cirka 2 år. Med hjälp av egenvård kan prognosen och förmågan att utföra vardagliga sysslor förbättras.  Syftet var att undersöka vilken betydelse personcentrerad vård kunde ha för personer med hjärtsvikt gällande egenvård, livskvalitet och symtombörda.  Metoden som användes var en litteraturstudie som inkluderade tio kvantitativa studier. Artiklarna valdes från databaserna PubMed och CINAHL. Dorothea Orems omvårdnadsteori användes som teoretisk referensram i studien. Resultatet påvisade att en personcentrerad vård kan förbättra egenvården hos personer med hjärtsvikt. Några resultat visade att personcentrerad vård gav en förbättring gällande livskvalitet, medan andra resultat inte visade på en signifikant förbättring gällande livskvalitet. En personcentrerad vård visade ingen förbättring på symtombördan hos personer med hjärtsvikt. Slutsatsen var att en personcentrerad vård förbättrar egenvården hos personer med hjärtsvikt. Personcentrerad vård kan i vissa fall även leda till en förbättrad livskvalitet, men det visade ingen förbättring gällande symtombördan hos personer med hjärtsvikt. / Heart failure affects circa two percent of the population and the illness affects the person’s everyday life and the ability to perform everyday tasks. The prognosis for heart failure is serious, people that have been diagnosed with heart failure have a median survival time of approximately 2 years. With the help of self care the prognosis and the ability to perform everyday tasks can be improved.  The aim of this study was to examine what importance person centered care have for people with heart failure concerning self-care, quality of life and symptom burden.  The method that was used was a literature study which included ten quantitative studies. The articles were chosen from the databases PubMed and CINAHL. Dorothea Orem’s nursing theory was used as theory framework in this study. The results showed that a person centered care may improve self-care in people with heart failure. Some results showed that a person centered care improved quality of life, while other results did not show any significant improvement on quality of life. A person centered care did not show any improvement in symptom burden for people with heart faliure.  The conclusion was that person centered care may improve self-care for people with heart failure. Person centered care may in some cases also result in an improved quality of life, but it did not show any improvement in the symptom burden for people with heart failure.

Bakgrund: Distriktsköterskan inom kommunal hemsjukvård är en central person inom den palliativa vården. Patienter som lider av kronisk hjärtsvikt och är under palliativ vård riskerar att inte få samma behandling eller vård under den sista tiden som andra palliativa patienter. Brist på erfarenhet och utbildning av vårdpersonal samt att ledarskapet i organisationen är en av flera faktorer som påverkar att palliativa hjärtsviktspatienter inte får en skräddarsydd vård. Syfte: Att beskriva distriktsköterskors upplevelse av att vårda palliativa patienter med hjärtsvikt inom den kommunala hemsjukvården. Metod: Kvalitativ design med kvalitativ innehållsanalys. Resultat: I resultatet framkom två kategorier; Organisationens påverkan på distriktsköterskornas yrkesutövning med subkategorierna Distriktsköterskornas kompetens, utveckling och teamarbete samt Palliativa vårdens huvudmän och ledarskap. Den andra kategorin; Distriktsköterskornas professionella förhållningssätt med subkategorierna Distriktsköterskans bemötande av patienter och anhöriga samt Distriktsköterskans upplevelse av vårdplaner. Slutsats : Distriktsköterskorna behöver fortbildning för att känna säkerhet och tillfredsställelse i vården av hjärtsviktspatienter och bemötandet av anhöriga. Det är viktigt att stärka och stimulera distriktsköterskornas teamarbete vilket skapar en positiv arbetsmiljö. Dokumentationssystemet för vårdplanerna behöver bli mer lättanvänt och tydligt för att förbättra den palliativa vården för hjärtsviktspatienterna. / Background: District nurses in the community health service are one of the main providers of palliative care. Chronic heart failure patients could suffer from lack of treatment or correct care in comparison to other groups of palliative care patients. Lack of experience, education in health professionals and the leadership within the organisation are one of several factors for palliative chronic heart failure patients to not receive tailor dressed care Aim: To explore district nurses view of caring for palliative chronic heart failure patients in community health service Method : Quality design and interviews were analyzed by a quality content analysis. Result: The results resulted in two categories; The organizations influence public health nurses daily work with two subcategories, The competence, development and team work of the public health nurses and the palliative care organisations and leadership. The second category was, Public health care nurses’ professional approach with subcategories Public health care nurse’s treatment of patients and relatives and Public health care nurse’s experiences of care plans. Conclusion: District nurses need continuously education enabling to feel secure and satisfaction in the care and reception of palliative heart failure patients and relatives. It´s important to enhance the teamwork to create a positive work environment for the District nurses. Care plan systems must be suitable and user friendly to improve the palliative care for chronic heart failure patients.

Introdução: Distúrbios nutricionais são frequentes em pacientes com insuficiência cardíaca (IC) e associados a pior prognóstico. Entretanto, a grande variabilidade de critérios diagnósticos e a diversidade das populações estudadas tornam pouco reprodutíveis os resultados. São escassos os dados a respeito da ocorrência de distúrbios nutricionais em pacientes com IC no âmbito nacional. Objetivo: Estudar a ocorrência da desnutrição e caquexia em pacientes com insuficiência cardíaca descompensada (ICD) e sua influência no prognóstico hospitalar. Metodologia: Trata-se de uma coorte prospectiva de pacientes com idade superior a 18 anos internados com descompensação de IC e fração de ejeção do ventrículo esquerdo (FEVE) inferior a 50%. Os pacientes foram submetidos a avaliação nutricional que incluiu anamnese, avaliação nutricional subjetiva global (ASG), medidas antropométricas e foram diagnosticados quanto a presença de desnutrição, caquexia, baixo teor muscular e baixa força muscular. Dados bioquímicos, clínicos e de função ventricular foram obtidos por revisão do prontuário. Foram estudados os desfechos: alta hospitalar, óbito ou necessidade de transplante cardíaco em regime de urgência. Resultados: Foram analisados 131 pacientes, 64,9% eram do sexo masculino, a mediana de idade foi de 56 anos (IQ25-75: 45-64), 40,5% apresentavam cardiomiopatia dilatada, 32,1% doença de Chagas e 19,1% cardiomiopatia isquêmica. Os pacientes apresentaram mediana de FEVE de 25% (20-30) e de BNP de 1093pg/ml (591-2149). Quanto à avaliação nutricional a mediana de IMC foi de 23,3kg/m2 (20,6-26,7), 25,2% apresentaram baixo peso segundo o IMC, 41,2% baixo teor muscular, 49,6% baixa força muscular, 61,8% receberam diagnóstico de desnutrição e 48,1% de caquexia. Quanto ao desfecho hospitalar, 26% foram a óbito e 29% foram submetidos ao transplante cardíaco. A presença de distúrbios nutricionais esteve relacionada com algumas características clínicas, de forma que foi encontrado um pior perfil nutricional em indivíduos do sexo masculino, com doença de Chagas, adultos e que apresentavam maior severidade da IC. Os pacientes que tiveram os piores desfechos apresentavam menor FEVE, menor IMC, menos massa muscular, maiores níveis séricos de peptídeo natriurético tipo B e eram mais frequentemente desnutridos e caquéticos, porém na análise multivariada essa relação não se mostrou de forma independente. Conclusões: Nossos achados revelam que há uma alta ocorrência de desnutrição e caquexia entre pacientes internados com ICD em nosso meio, e que variáveis indicativas de pior status nutricional estão associadas com piores desfechos durante a internação / Introduction: Nutritional disorders are common among patients with heart failure (HF) and associated with poor prognosis. However, the great variability of the diagnostic criteria and the diversity of the populations studied make results poorly reproducible. There are few data about nutritional disorders in patients with HF at the national level. Objective: To study the occurrence of undernutrition and cachexia in patients with decompensated HF and its influence on hospital prognosis. Methods: Prospective cohort study of adults and elderly patients hospitalized with decompensated HF and left ventricular ejection fraction (LVEF) less than 50%. The patients were submitted to nutritional evaluation including anamnesis, Subjective Global Nutritional Assessment (SGA), anthropometric measurements and were diagnosed for the presence of undernutrition, cachexia, low muscle mass and low muscle strength. Biochemical, clinical and ventricular function data were obtained by reviewing the medical record. We studied the outcomes: hospital discharge, death or need for heart transplantation during hospitalization. Results: 131 patients were analyzed, 64.9% were male, the median age was 56 years (IQR: 45-64), 40.5% had dilated cardiomyopathy, 32.1% Chagas disease and 19.1% ischemic cardiomyopathy. Patients had a median LVEF of 25% (20-30) and B-type natriuretic peptide (BNP) of 1093pg/ml (591-2149). Regarding nutritional assessment, the median Body Mass Index (BMI) was 23.3 kg/m2 (20.6-26.7), 25.2% presented low body weight according to BMI, 41.2% low muscle mass, 49.6% low strength muscle, 61.8% were diagnosed as undernourished and 48.1% were cachectic. Regarding the hospital outcome, 26% died and 29% received cardiac transplantation. The presence of nutritional disorders was related to some clinical characteristics, in order that a worse nutritional profile was found in patients that was male, with Chagas\' cardiomyopathy, adults and who presented a higher severity of HF. Patients who had the worst outcomes had lower LVEF, BMI, lower muscle mass, higher serum levels of BNP and were more often undernourished and cachectic, but in the multivariate analysis, this relationship was not shown independently. Conclusions: Our findings show that there is a high occurrence of undernutrition and cachexia among hospitalized patients with decompensated HF in our setting, and that variables indicative of poor nutritional status are associated with worse outcomes during hospitalization

Micro-encapsulation of heart explant-derived stem cells (EDCs) within protective nanoporous gel (NPG) cocoons improves cardiac function and long-term retention of transplanted cells after ischemic injury by limiting detachment induced cell death and vascular clearance of intramyocardial injected cells. Although cocooned EDCs boost cardiac function, the fundamental mechanism is unclear. Here, we investigate the effects of altering cocoon stiffness and size on human EDC mediated repair of damaged myocardium using an immunodeficient mouse model of ischemic cardiomyopathy. First, we found that increasing cocoon stiffness by altering NPG content boosted cell viability and migration; effectively forcing cocooned cells to adopt a migratory, invasive phenotype. Although cocooning improved retention of transplanted cells, increasing cocoon stiffness had no additional effects on long-term engraftment despite markedly improving cardiac function and fibrosis after myocardial infarction. Given increased cocoon stiffness boosted the production and microRNA cargo within EDC nanovesicles, the observed benefits in post-ischemic function are likely dependent more on paracrine production of transplanted cells rather than simply increasing the number of cells retained. The effect of cocoon diameter on EDC phenotype and cell mediated repair of ischemic myocardium was evaluated using microfluidic-based cocooning enabling deterministic encapsulation within defined cocoon size and intracapsular cell number while maintaining a fixed cocoon stiffness. Increased cocoon size enhanced post-ischemic cardiac function by reducing clearance of transplanted cells and increased paracrine stimulation of endogenous repair. The latter being attributable to microfluidic cocooning closely following the expected Poisson distribution with smaller cocoons having a greater proportion of single cells while larger cocoons contained greater proportions of multicellular aggregates which enhanced cell-cell interactions to increase the amount and breadth of cytokines/nanoparticles delivered to injured myocardium. In conclusion, altering the biophysical properties of NPG surrounding cocooned cells provides a straightforward means of boosting the regenerative potential of heart EDCs for repair of injured myocardium.