Syftet med denna studie var att belysa hur viktig nutritionen är för patienter med diagnosen KOL (Kronisk Obstruktiv Lungsjukdom). Författarna ville även visa på enkla metoder för sjuksköterskan att bedöma nutritionsstatus för att förebygga malnutrition hos dessa patienter. Denna studie är en systematisk litteraturstudie där författarna använt sig av databaserna ELIN@Dalarna, CINAHL, Blackwell Synergy och SWEMED+ för att söka vetenskapliga artiklar. Sökorden som användes i olika kombinationer var: COPD, nutrition, malnutrition, undernutritioned, nutritionalstatus, nutritional supplement, BMI, energy expenditure, caring och nursing. Resultatet visade att nutritionen är av central betydelse i behandlingen av KOL patienter där sjuksköterskan har en viktig roll i samarbetet med andra yrkeskategorier såsom läkare, dietist, sjukgymnast, arbetsterapeut, kurator och psykolog. Bedömningen av patientens nutritionsstatus är en väsentlig del av sjuksköterskans omvårdnad av KOL patienter då det påverkar prognosen. Patienternas försämrade nutritionsstatus ökar risken för exacerbationer och därmed också risken för dödlighet.Sjuksköterskan kan använda sig av enkla mätmetoder för att upptäcka malnutrition, till exempel BMI (Body Mass Index) och MNA (Mini Nutritional Assessment). Ett steg i att förebygga malnutrition är regelbundna viktkontroller och att varje patient har en individuell åtgärdsplan då patientens behov alltid ska komma i första hand. Det är också viktigt att se till psykosociala aspekter runt måltiderna för dessa patienter. En noggrann planering krävs runt deras måltider som patienten kan behöva hjälp med då sjukdomen utgör ett hinder.För en ökad livskvalitet är det angeläget med information om nutritionens betydelse både till patienten och hans anhöriga.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23370号 / 医博第4739号 / 新制||医||1051(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 椛島 健治, 教授 竹内 理, 教授 森信 暁雄 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

Introduction: Takotsubo cardiomyopathy or stress cardiomyopathy is a syndrome of transient left ventricular (LV) dysfunction mimicking myocardial infarction, but lacking obstruction of coronary artery disease (CAD) or acute plaque rupture. A characteristic differentiation from CAD is that regional motional abnormality extends beyond a territory perfused with a single epicardial coronary artery. Clinically, it is characterized by apical ballooning of the LV due to due to depression of mid and apical segments, with hyperkinesis of cardiac basal walls. Women are affected more than men, predominantly in the postmenopausal age. Case Report: A 54-year-old Caucasian female with a history of COPD, hypertension, uncontrolled diabetes mellitus, hyperlipidemia, depression and ongoing tobacco use presented with complaints of worsening shortness of breath two days prior to admission. She denied chest pain, worsened cough, palpitations, nausea or vomiting. On examination, she was in distress and anxious, with labored breathing. Upon examining the chest, decreased air entry was present in both lung fields with bibasilar wheezing. Initial lab tests showed mild respiratory acidosis, with pH of 7.24, pCO2 of 47.4 and pO2 of 65. Troponins on the day of admission was Soon after admission, she started complaining of severe right neck pain. Repeat EKG revealed localized lateral J point, anteroseptal q waves and 4mm ST-segment elevation in leads V3 and V4 reciprocal changes and without chest pain. Repeat troponins were slightly elevated to 0.42 ng/ml and CK-MB was elevated to 20.2 ng/ml. A transthoracic echocardiogram showed regional abnormalities in left ventricle with the apex, mid to distal septum and the anterior part of septum was akinetic. Discussion: Takotsubo cardiomyopathy presents in 1 to 2 percent of troponin-positive acute coronary syndrome (ACS) with various clinical manifestations and various outcomes. Some patients have favorable outcomes based on their clinical performance and extent of cardiac muscle involvement. As in the case we presented, this syndrome can be entirely idiopathic, without a definitive underlying cause. Supportive management while hospitalized and early identification of complications improve the prognosis.

Le maintien de l'intégrité de l'épithélium des voies aériennes est assuré par un mécanisme de réparation épithéliale pouvant être dérégulé dans la bronchopneumopathie chronique obstructive (BPCO). La BPCO, définie par une obstruction irréversible des débits aériens et émaillée d'épisodes d'exacerbation, présente différents phénotypes, pour lesquels l'évaluation de la sévérité tient compte de la fonction respiratoire et de données cliniques. L'objectif de cette thèse était d'étudier du point de vue phénotypique des patients BPCO lors des exacerbations virales et au cours du processus de réparation épithéliale. Nous avons étudié prospectivement 51 patients BPCO suivis mensuellement et lors des exacerbations. Virus et bactéries étaient recherchés dans l'expectoration induite par PCR et culture. Les résultats analysés en fonction des données cliniques et fonctionnelles respiratoires ont montré qu'une coinfection, présente dans 25% des exacerbations, n'était pas associée au phénotype des patients ni à la sévérité ou à la récidive de l'exacerbation. Nous avons ensuite étudié la réparation de cellules épithéliales bronchiques primaires dans un modèle de réparation de lésion. L'analyse des paramètres de fermeture de lésion (vitesse de fermeture, sécrétions, prolifération cellulaire) en fonction des données cliniques, fonctionnelles et histologiques a montré notamment que la vitesse de fermeture était associée à la sévérité de l'obstruction bronchique. Ces résultats suggèrent le rôle d'anomalies de réparation épithéliale dans la physiopathologie de la BPCO et soulignent la complexité du phénotypage des patients atteints de BPCO. / The integrity of airway epithelium is provided by a complex mechanism of epithelial repair that can be dysegulated in chronic obstructive pulmonary disease (COPD). COPD is a heterogeneous condition defined by an irreversible obstructive airflow limitation with frequent acute episodes of exacerbations. COPD patients can present different phenotypes, for which severity evaluation must take into account the severity of lung function and clinical data. The aim of this thesis was to study the COPD patients in a phenotypic point of view during viral exacerbations and during the process of epithelial repair.We prospectively studied 51 COPD patients monitored monthly and during exacerbations. Induce sputum were analyzed for viruses and bacteria detection by PCR and culture. These results analyzed according to the clinical and functional respiratory data showed that co-infection was present in 25 % of exacerbations and was not associated with the phenotype of patients or the severity or recurrence of exacerbation.We then studied primary bronchial epithelial cells repair in a model of wound closure. Associations between wound closure parameters (speed of wound closure, secretions, cell proliferation) and clinical, histological and functional data were analyzed. We showed that the speed of wound closure was associated with the severity of bronchial obstruction. These results suggest the role of abnormal epithelial repair in the pathogenesis of COPD and highlight the complexity of phenotypic characterization of COPD patients.

Bakgrund: Kronisk obstruktiv lungsjukdom (KOL) sjukdom är ett växande problem världen över och kommer i framtiden att ställa primärvården inför utmaningar att kunna möta komplexa vårdbehov från den här patientgruppen. KOL innebär begränsningar i det dagliga livet och ger känslor av beroende vilket gör att många patienter är i behov av kontakt med primärvårdens vårdcentraler. Försämrad andning (exacerbation) är ofta anledning till att en patient med KOL ringer till vårdcentralen. Sjuksköterskan i telefonrådgivningen ställs inför utmaningar att kunna bedöma patientens försämrade andning. Syfte: Att beskriva sjuksköterskors erfarenheter att i telefonrådgivning på vårdcentralen bedöma andningsförsämring hos patienter med KOL och besluta om vidare åtgärd.  Metod: En kvalitativ studie har genomförts med individuella semistrukturerade intervjuer där elva sjuksköterskor som arbetar med telefonrådgivning på vårdcentral deltog. En kvalitativ innehållsanalys användes för analys av intervjutexterna  Resultat: Hur sjuksköterskorna erfor bedömningen av patienternas försämrade andning utmynnade i fyra huvudkategorier med tio underkategorier samt ett övergripande tema: Att utan sin kliniska blick bedöma andningsförsämring vid KOL innebär utmaningen att värdera patientens aktuella symtom, i förhållande till tidigare och ta beslut om åtgärd.  Slutsats: Ett centralt fynd i den här studien är att det finns utmaningar i telefonrådgivning för att bedöma andningssvårigheter hos patienter med KOL. Avsaknaden av den kliniska blicken i telefonrådgivning ställer krav på kompetens och kommunikativa färdigheter hos sjuksköterskan. Samtidigt finns det möjlighet att hitta stöd för sin bedömning i formella beslutstöd och kollegor för att möjliggöra ett adekvat beslutsfattande / Background: Chronic obstructive pulmonary disease (COPD) is a growing problem worldwide and will in the future pose primary care challenges to be able to meet complex care needs from this patient group. COPD means limitations in daily life and feelings of dependence, which means that many patients need contact with primary health care. Respiratory impairment (exacerbation) is often the reason why patients with COPD call the health care center. The nurse in the telephone counseling is faced with challenges to be able to assess the patient's respiratory impairment. Aim: To describe nurses' experiences of assessing respiratory impairment in patients with COPD in telephone counseling at the health care center and make further decision.Method: A study employed qualitative design using individual semi-structured interviews as data collection method with participation of eleven nurses working with telephone counseling at health care centers. A qualitative content analysis was used to analyze the interviews.Results: The way the nurses experienced the assessment of patients' respiratory impairment was revealed in terms of four main categories, ten subcategories and grasped by one overarching theme: Without visual contact, assessing respiratory impairment in patients with COPD presents a challenge to value the patient´s current symptoms, in relation to the past, and make decision. Conclusion: One core finding of this study is that there are challenges and difficulties in telephone counseling to assess respiratory impairment in patients with COPD. The lack of visual contact with the patients in telephone counseling places demands on the nurse's competence and communication skills. At the same time, nurses receive support for their assessment in decision-making tools and by colleagues.

BACKGROUND: Constipation is highly prevalent in older adults and may be associated with greater frequency of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We investigated the prevalence of lower defecation frequency (DF) and risk factors (including AECOPD) associated with lower DF among hospitalized elderly patients. METHODS: We conducted a retrospective case-control study in a community hospital of Southeast Ohio. Adults aged 65 years or older admitted during 2004 and 2006 were reviewed (N = 1288). Patients were excluded (N = 212) if their length of stay was less than 3 days, discharge diagnosis of Clostridium difficile-associated diarrhea, death or ventilator- dependent respiratory failure during hospitalization. Lower DF was defined as either an average DF of 0.33 or less per day or no defecation in the first three days of hospitalization; cases (N = 406) and controls (N = 670) were included for the final analysis. RESULTS: Approximately 38% had lower DF in this patient population. Fecal soiling/smearing of at least two episodes was documented in 7% of the patients. With the adjustment of confounders, AECOPD (adjusted odds ratio [AOR] =1.47, 95% confidence interval [CI] =1.01-2.13) and muscle relaxant use (AOR =2.94; 95% CI =1.29-6.69) were significantly associated with lower DF. Supplementation of potassium and antibiotic use prior to hospitalization was associated with lower risk of lower DF. CONCLUSIONS: Approximately 38% of hospitalized older adults had lower DF. AECOPD and use of muscle relaxant were significantly associated with lower DF; while supplementation of potassium and antibiotic use were protective for lower DF risk after adjusting for other variables.

Orientador: Suzana Erico Tanni Minamoto / Resumo: Introdução: A exacerbação aguda é uma importante causa de perda de função em pacientes com doença pulmonar obstrutiva crônica (DPOC). Afeta negativamente a qualidade de vida, a função pulmonar, a fraqueza muscular, o uso de recursos de saúde e a sobrevivência. Acredita-se que o exercício físico realizado durante a exacerbação pode melhorar a qualidade de vida e a capacidade física do paciente sem aumento do processo inflamatório. Objetivo: Avaliar a influência do exercício físico aeróbico de curta duração durante a internação em marcadores inflamatórios, qualidade de vida e capacidade física, além de re-hospitalização e taxas de mortalidade seis meses após a alta hospitalar em pacientes com DPOC exacerbada. Pacientes e Métodos: 26 pacientes foram avaliados 24 horas após a hospitalização por características demográficas, história de tabagismo, índice de Charlson, qualidade de vida, marcadores inflamatórios sistêmicos e composição corporal. Após 48 horas de internação, todos os pacientes realizaram o teste de caminhada de 6 minutos e um novo teste de espirometria, sendo calculado o índice BODE. Após 72 horas de internação, os pacientes do grupo de intervenção foram submetidos a exercícios aeróbicos em esteira por 15 minutos, duas vezes ao dia. Por fim, um mês após a alta hospitalar, todos os pacientes foram reavaliados segundo a qualidade de vida, marcadores inflamatórios sistêmicos, composição corporal, espirometria, teste de caminhada de 6 minutos e índice BODE. Resultados: O... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Acute exacerbation is an important cause of loss of function in patients suffering from chronic obstructive pulmonary disease (COPD). It negatively affects the quality of life, lung function, muscle weakness, use of health resources and survival. It is believed that the physical exercise performed during the exacerbation can improve the quality of life and the physical capacity of the patient without an increase in the inflammatory process. Objective: To evaluate the influence of short-term aerobic physical exercise during hospitalization on inflammatory markers, quality of life and physical capacity, as well re-hospitalization and mortality rates six months after hospital discharge in patients with exacerbated COPD. Patients and Methods: 26 patients were evaluated 24 hours after hospitalization for demographic characteristics, smoking history, Charlson index, quality of life, systemic inflammatory markers and body composition. After 48 hours hospitalization, all patients performed a 6-minute walk test and a new spirometry test, and BODE index was calculated. After 72 hours of hospitalization, patients in the intervention group underwent aerobic exercise on a treadmill for 15 minutes twice daily. Finally, a month after hospital discharge, all patients were re-evaluated according to quality of life, systemic inflammatory markers, body composition, spirometry, 6-minute walk test and BODE index. Results: Patients in the intervention and control group did not differ... (Complete abstract click electronic access below) / Doutor

Viral respiratory infections (VRI) are common in children with cystic fibrosis (CF) and are associated with significant clinical deterioration. Little previous research has been conducted on VRI in adults with CF. This thesis describes a prospective study to determine the epidemiology and clinical impact of VRI among 100 adults with CF.The incidence of identifiable VRI was 1.66 cases/patient-year. Rhinovirus accounted for 72.5% of viruses. Identifiable VRI was associated with increased risk of pulmonary exacerbation, increased respiratory symptoms and higher C-reactive protein levels. Changes in the climate and seasons affected the incidence of identifiable VRI. Rhinovirus was most common in autumn and other viruses predominated during winter. Warmer ambient temperatures were associated with increased risk of rhinovirus infection while other viruses were more common in colder temperatures. Genetic sequencing of a subset of 42 rhinoviruses identified during the study showed that rhinovirus A accounted for 69% of cases and was associated with more severe respiratory symptoms and higher C-reactive protein levels than rhinovirus B.The impact of identifiable VRI on changes to bacterial communities within the lungs of patients with CF was investigated. Ribosomal intergenic spacer analysis (RISA) was developed as a tool to profile the bacterial diversity of CF sputum and was compared with standard culture and 16S rRNA gene pyrosequencing. No consistent effect of identifiable VRI on the microbial diversity of CF sputum was detected with any of these methods in longitudinal analysis of a subset of 18 patients.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第24808号 / 社医博第132号 / 新制||社医||12(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 西浦 博, 教授 平井 豊博 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Background: The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014. Methods: This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses. Results: 189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16–1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases’ aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289). Conclusion: OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.