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Abstract Introduction The study aimed to assess and improve the quality of care for congestive cardiac failure in a public sector, primary health care setting, in Cape Town. There is currently no literature available on the quality of care for the management of congestive cardiac failure in primary health care in South Africa. Methods A disease register was constructed by identifying patients prescribed Furosemide and checking the medical records. Altogether 95 patients with CCF were identified. The study followed the usual steps for a quality improvement cycle: Formation of an audit team; agreeing on criteria based on current CCF guidelines; collection of data from medical records to measure the criteria; analysis and feedback of results to the staff; critical reflection, planning and implementing change; re-audit of the medical records. Results There was a mean age of 63.4 years, 21% were male and 75% were females. The results of the initial audit revealed suboptimal management of patients diagnosed with CCF: 53% had an aetiological diagnosis recorded in the clinical notes, 24% had a documented functional capacity, 12% of patients had documented precipitating/exacerbating factors, 58% had fluid status documented, and 37% had documentation of their cardiac rate and rhythm. The intervention consisted of feedback on the audit results and critical reflection with the relevant staff members. The doctors were provided with a printed protocol to refer to for the management of CCF. Clinicians were resistant to change and to taking on new tasks in relation to the management of patients with CCF and decided to only focus on improving the clinical assessment of patients. The results of the re-audit after 5-months in 40 patients demonstrated improvement in the clinical assessment criteria: 95% of the patients had an aetiological diagnosis recorded in the notes, 50% had a documented functional capacity, 42% had documented precipitating/exacerbating factors documented, 72% had their fluid status documented, and 85% of patients had their cardiac rate and rhythm documented. None of the five assessment criteria were met at baseline but post-intervention three of the five met the target set and all showed substantial improvement. There was no improvement noted in any of the other criteria, which were not specifically focused on in the plan to improve clinical practice. Conclusion The current quality of care for CCF in primary health care is poor and needs to be improved. The quality improvement cycle led to substantial improvement in the clinical assessment of patients with CCF. Recommendations are made regarding future criteria, which could be included in local audit tools.

Introduction: The development of liver fibrosis is characterised by dramatic changes in the biomechanical composition and mechanical properties of the extracellular matrix (ECM). Increases in matrix stiffness associated with inflammation and fibrosis are implicated in promoting cancer development. Clinical studies have demonstrated a close association between increases in liver stiffness and the incidence of hepatocellular carcinoma (HCC). The effect of changes in matrix stiffness on tissue-resident hepatic progenitor cells (HPC) is unknown. Aberrant HPC proliferation has been implicated in the pathogenesis of HCC. It was hypothesised that changes in the stiffness of the cellular microenvironment are important in regulating the behaviour of liver-resident cell populations and may promote the development of HCC. Aims: i) to determine how changes in the stiffness of the cancer cell niche might regulate proliferation, differentiation and chemotherapeutic resistance in HCC; ii) to determine the relationship between changes in liver stiffness and hepatic progenitor cell (HPC) response in rodent models of chronic liver disease; and iii) to determine whether changes in the stiffness of the HPC niche regulate proliferation and differentiation in these cells. A secondary aim of the thesis was to characterise the pattern of histological changes observed in rodent models of chronic hepatic congestion and whether this might provide insight into the effect of oedema and congestion on the development of liver fibrosis. Methods: Cell culture experiments in HCC (Huh7/ HepG2) and HPC cell lines were performed using a system of ligand-coated polyacrylamide (PA) gel supports of variable stiffness. The stiffness of the PA supports (expressed as shear modulus) was altered across a physiological change (1-12kPa) corresponding to values encountered in normal and fibrotic livers. Thiacetamide and carbon tetrachloride (CCl4) models of liver fibrosis were used to investigate the relationship between increasing liver fibrosis, changes in matrix stiffness and HPC response. The pattern of histological changes in the liver in response to hepatic congestion was assessed in two unrelated murine models of dilated cardiomyopathy; the python and CREB S133A mice. Results: Increases in matrix stiffness, as would be encountered in liver fibrosis, promote HCC cell proliferation. Increasing matrix stiffness is associated with enhanced basal and hepatocyte growth factor-mediated signalling though ERK, PKB/ Akt and STAT3. Stiffness-dependent HCC cell proliferation is modulated by β1-integrin and focal adhesion kinase. Increasing matrix stiffness is associated with a reduction in chemotherapy-induced apoptosis in HCC cells. However, following chemotherapy there was an increase in the frequency of clone-initiating cells for cells maintained in a low stiffness environment. Flow cytometry in HepG2 cells demonstrated that culture in a low stiffness environment was associated with an increase in the frequency of the stem cell markers CD44, CD133 and CXCR-4. This effect was further enhanced in the presence of chemotherapy. There is a close association between HPC numbers and liver stiffness measurements in a rat CCl4 model of chronic liver fibrosis. The major expansion in HPC numbers in this model coincides with a similarly large increase in fibrous tissue deposition. In vitro experiments using PA supports demonstrate that increasing matrix stiffness promotes the proliferation of both primary murine HPCs and an immortalised HPC line (BMOL). Changes in matrix stiffness regulate the expression of hepatocyte and biliary markers in BMOL cells. Histological studies in both the Python and CREB S133A models reveal findings consistent with acute on chronic cardiac hepatopathy (ischaemic hepatitis). Features of chronic passive congestion and centrilobular necrosis are present concurrently and develop rapidly. Bridging fibrosis and cirrhosis are not present. Conclusions: Physiologically-relevant changes in matrix stiffness regulate proliferation, differentiation, chemotherapeutic-resistance and stem cell marker expression in HCC cells. Similarly, increases in matrix stiffness are closely correlated to HPC response in vivo and regulate HPC proliferation and differentiation in vitro.

Bakgrund: Hjärtsvikt är en växande folksjukdom som drabbar allt fler individer i världen. Hjärtsvikt är ett tillstånd när hjärtat inte kan pumpa tillräckligt med blod för att tillgodose kroppens behov, vilket påverkar både hälsan och det vardagliga livet. För att sjuksköterskor ska kunna ge god vård till personer med hjärtsvikt krävs det kunskap och förståelse kring upplevelsen av att leva med hjärtsvikt. Syfte: Att beskriva personers upplevelse av att leva med hjärtsvikt.   Metod: En litteraturöversikt med utgång i forskning med kvalitativ design och induktiv ansats. Resultatartiklar insamlades från databaserna CINAHL, MedLine och PsycInfo som analyserades med hjälp av Fribergs femstegsanalys. Resultat: I resultatet uppkom tre teman och sex underteman. Dessa teman beskriver vilka förändringar hjärtsvikt förde med sig och hur det påverkade vardagen. Slutsatser: I litteraturöversikten framkom det olika aspekter av att leva med hjärtsvikt. Hjärtsvikt skapade begränsningar och emotionella förändringar i livet. Bristen på information från sjukvården försvårade hanteringen av hjärtsvikt. Nivå av KASAM kan påverka förutsättningar till att kunna hantera sjukdomen. För att underlätta omvårdnad och stöttning är det betydelsefullt att sjuksköterskor inneha kunskap och förståelse för upplevelsen av att leva med hjärtsvikt. / Background: Heart failure is a growing public health problem and is affecting many people around the world. Heart failure is a condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs which affect the health and the daily life. For nurses to be able to provide good healthcare, it requires knowledge of experience of people living with heart failure. Aim: To describe people’s experience of living with heart failure. Method: A literature review based on qualitative design and inductive approach. Result articles were collected from the databases CINAHL, MedLine and PsycInfo and analyzed using Friberg’s five-step analysis. Result: The result revealed tree themes and six sub-themes. These themes describe how heart failure changed and affected everyday lives of people living with it. Conclusion: The literature study revealed various aspects of living with heart failure. Heart failure created limitations and emotional changes in life. The lack of knowledge from the healthcare made managing heart failure difficult. The level of SOC can affect the prerequisites of managing the disease. It is important that nurses have knowledge and understanding of the experience of living with heart failure, to facilitate nursing.