Design evaluation of a home-based telecare system for Chronic Heart Failure patients.

In order to improve the care of Chronic Heart Failure (CHF) patients, a system has been developed for monitoring symptoms and document subjective judgments on health conditions in a home environment. Since system usability is an important issue, a two step evaluation of the solution was conducted. First a ten-patient survey was conducted, which was aimed at spotting possible problem areas. The second step involved a small trial in a home setting with CHF patients. The results are promising, indicating that the system is user friendly and easy to use, and that it is suitable as a prototype for the intended use.

Intestinal paracellular permeability is not affected in chronic congestive heart failure.

BACKGROUND: In chronic heart failure (CHF) it has been proposed that a dysfunction of the gastrointestinal barrier could lead to translocation of endotoxin into the systemic circulation. A secondary inflammatory reaction, observed as increased levels of cytokines, could negatively affect cardiac function. The aims of this paper were therefore to determine whether patients with CHF have a disturbed mucosal barrier and whether it was possible to detect endotoxin in venous blood. METHODS: Nineteen stable patients with CHF (New York Heart Association II-III, EF40% and earlier hospitalisation for heart failure) were investigated. Twenty healthy subjects (HS group) and 25 patients, who were admitted for bone marrow transplantation (BMT group), served as controls. Gastrointestinal permeability was assessed by a (51)Cr-EDTA absorption test. RESULTS: Eleven patients with and eight without peripheral oedema were included. Median age was 76.5 years. Intestinal permeability was 1.82+/-1.96% in the CHF patients and 1.54+/-.59% and 1.9+/-.9% in HS and BMT groups, respectively (p=0.4 and p=0.7, CHF vs HS and BMT, respectively). No difference was found between patients with and without oedema and endotoxins were below the detection limit in all patients. DISCUSSION: This study does not support the hypothesis that patients with CHF have a dysfunctional gastrointestinal barrier, at least as assessed by the (51)Cr-EDTA resorbtion test.

Adaptation of cardiac morphology and function to endurance and strength training. A comparative study using MR imaging and echocardiography in males and females.

Left ventricular (LV) dimensions and function and maximal oxygen uptake (VO(2)max) were measured in endurance-trained (10 male, m, 10 female, f), strength-trained athletes (8 m, 10 f) and untrained subjects (9 m, 10 f). LV dimensions were measured using magnetic resonance imaging (MRI) and echocardiography and the results were equal irrespective of method. Endurance-trained m and f had significantly higher LV volumes and mass than both strength-trained and controls. No VO(2)max or dimensional differences were seen between strength-trained and untrained subjects. In endurance-trained males, LV volumes and mass/kg bw were higher than in endurance-trained females. There was no significant gender difference for strength-trained or untrained subjects regarding body weight-related heart dimensions. It is concluded that LV dimensions and volumes are strongly dependent on oxygen transport capacity in normal subjects practising different modes of training, and that the gender differences, if LV dimensions are related to aerobic work capacity, are smaller than previously reported.

The clinical implications of cognitive impairment in elderly patients with chronic heart failure.

The purpose of this study was to examine whether cognitive dysfunction was associated with poor participation in an outpatient treatment program for patients with chronic heart failure and if it was related to specific patient characteristics. Cognitive function was measured with the Mini Mental State Examination (MMSE). Twenty-three of 78 (29%) patients randomized to structured care did not participate in this program and nonparticipation during 6-month follow-up was associated with an MMSE score below the median and a low calculated creatinine clearance (CrCl) (R2=0.15, p=0.0025) at entry. In the entire group long duration of heart failure and low blood hemoglobin concentration were independently associated with an MMSE score below the median at entry (R2=0.14, p < 0.0001). Among elderly patients hospitalized with moderate-severe chronic heart failure, judged to be eligible for a nurse-directed outpatient program after discharge, a low MMSE score predicted nonparticipation in such a program. Cognitive dysfunction, which was related to the duration of heart failure, should be evaluated in the treatment of patients with chronic heart failure.

The meaning of living with severe chronic heart failure as narrated by elderly people.

The meaning of elderly patients' experiences of living with chronic heart failure was studied. Narrative interviews were analysed using a phenomenological hermeneutic approach. 'Feeling imprisoned in illness' and 'feeling free despite illness' constituted the themes. These themes were interpreted as describing variations in awareness of the relationship between the self and the body. In theme 'feeling imprisoned in illness' the body's illness and disability hindered the subjects from being themselves. In the theme 'feeling free despite illness' the disabled body was not experienced as limiting, but rather as a part of the self. The patients' understanding of the illness must be interpreted by the caregiver, who also needs to be aware of different modes of communicating feeling about the illness.

The meaning of hospital care, as narrated by elderly patients with chronic heart failure.

Chronic heart failure is the most common reason for hospitalization among the elderly in western societies. To elucidate the meaning of the experience of care received in the hospital, as narrated by 12 elderly patients with severe chronic heart failure, interviews were analyzed by an approach inspired by Ricoeur's phenomenologic hermeneutics. The analysis revealed that the study respondents experienced the care as "unpredictable." This essential theme captured the divergent descriptions of 2 subthemes: care was either "confident but incomprehensible" or "nonconfident and incomprehensible." When the patients sought care, it was as though they were launching themselves into the unknown because they knew that many experiences would be unpredictable. Despite experiences of indifferent and unpredictable care, the narratives revealed a need to rely on the caregivers' expertise.

Feasibility of a nurse-monitored, outpatient-care programme for elderly patients with moderate-to-severe, chronic heart failure.

AIMS: To evaluate the feasibility of a nurse-monitored, outpatient-care program for elderly patients previously hospitalized with chronic heart failure. METHODS AND RESULTS: Patients with chronic heart failure hospitalized in the medical wards were screened to find those eligible for a randomized study to compare the effect of a nurse-monitored, outpatient-care programme aiming at symptom management, with conventional care. The inclusion criteria were patients classified in New York Heart Association classes III-IV, age 65 years, and eligibility for an outpatient follow-up programme. The total in-hospital population of patients discharged with a heart-failure diagnosis was surveyed. Eighty-nine per cent of all the hospitalized patients (n=1541) were 65 years old. Of these, 69% (n=1058) were treated in the medical wards which were screened. The study criteria were met by 158 patients (15%). No visits to the nurse occurred in 23 cases among the 79 patients randomized to the structured-care group (29%), mainly on account of death or fatigue. The numbers of hospitalizations and hospital days did not differ between the structured-care and the usual-care groups. CONCLUSIONS: Given the selection criteria and the outline of the interventions, the outpatient, nurse-monitored, symptom-management programme was not feasible for the majority of these elderly patients with moderate-to-severe, chronic heart failure, mainly because of the small proportion of eligible patients and the high drop-out rate. Management of these patients would have to be more adjusted to their home situation.

Deputed power of medical control: the hidden message in the ritual of oral shift reports.

The exchange of oral shift reports between nurses is a prominent part of the everyday routine in a hospital ward. Increased awareness of the more or less explicit functions of such communication is likely to have a positive impact on the nursing profession. Oral shift reports in a nursing care system based on task allocation were therefore observed and analysed. Using an ethnographic approach, reports were tape-recorded, and nurses were interviewed regarding their experiences. During the shift report session, the nurses were found to receive ritually mediated deputed power of medical control from their colleague, but little attention was paid to nursing needs and measures. The nurses clearly demonstrated that they were caught in a system dominated by a medical paradigm that effectively obstructed the progress of nursing as a professional discipline in its own right.

In vivo validation of the release rate and palatability of remoxipride-modified release suspension.

Remoxipride, a D2-dopamine receptor antagonist, is well tolerated and completely absorbed after oral administration. Because of its extremely bitter taste, an oral palatable suspension was developed by using a taste-masking microencapsulation. The bioavailability of remoxipride was investigated in two studies in healthy volunteers after administration of a 100-mg dose in suspension. The first study used a capsule as reference, and the second study a plain solution. Taste assessment was carried out in the second study. The extent of bioavailability was the same when comparing the oral suspension to a capsule and to a plain solution. However, the rate of absorption is delayed, and Tmax was 3.0 hr after the suspension, 1.0 hr after the oral solution, and 1.6 hr after the capsule. The release rate in vitro from the suspension was determined by applying the USP-paddle method. By using numerical convolution and deconvolution, the release rates in vivo and in vitro were shown to be similar when using water with 0.5% sodium lauryl sulfate as dissolution liquid. The taste-masked oral suspension is suitable for full-scale production, with good control of the encapsulation process and of the preparation of a suspension.

Absorption of drugs from continent caecal reservoir for urine.

The possibility of drug absorption from a continent caecal reservoir for urine was studied in 3 men with well functioning reservoirs. Saline solutions of digoxin, theophylline or terbutaline were instilled into the reservoir, each on a separate occasion, and drug concentrations in plasma and urine were measured for 24 h thereafter. Theophylline, but not terbutaline or digoxin, was absorbed from the reservoir. Estimated from an intravenous reference dose, the uptake of theophylline from the reservoir was approximately 50%. In patients with this type of urinary diversion, therefore, reabsorption from the continent caecal reservoir may complicate drug therapy.

The pharmacokinetics of theophylline and enprofylline in patients with liver cirrhosis and in patients with chronic renal disease.

We have studied the pharmacokinetics of theophylline and enprofylline in patients with liver cirrhosis, patients with chronic renal failure, and healthy subjects, and have assessed the predictive value of routine tests of liver function and renal function (creatinine clearance) for theophylline and enprofylline total body clearances. Theophylline clearance was significantly decreased in the patients with liver cirrhosis compared with both the patients with renal failure and the healthy subjects (the mean values in the three groups were 24, 47, and 46 ml.h-1.kg-1 respectively. Enprofylline clearance was significantly decreased in the patients with chronic renal failure, compared with both the patients with liver cirrhosis and the healthy subjects (the values in the three groups were 64, 250, and 289 ml.h-1.kg-1 respectively. There was a strong correlation between creatinine clearance and enprofylline clearance, while there was only a poor correlation between the liver function tests and theophylline clearance. It appears that in various clinical situations enprofylline elimination can be predicted more precisely than theophylline elimination, which may make the drug safer in clinical practice.

Pharmacokinetics of budesonide in children with asthma.

The pharmacokinetics of the glucocorticoid budesonide was studied in 6 children with asthma after i.v. injection of 0.5 mg and oral inhalation of 1 mg as an aerosol. Budesonide is a 1:1 mixture of the epimers 22 S and 22 R, which were assayed separately by HPLC combined with RIA. All pharmacokinetic parameters of the epimers differed except the half-life of about 1.5 h. It was significantly shorter than that reported in adults. Plasma clearance averaged 103 l X h-1 for epimer 22 R and 74 l X h-1 for epimer 22 S; calculated per kg body weight these values were about 50% higher than in adults. The difference was about 40% when calculated per m2 of body surface area. Since budesonide is a high-clearance drug, the data indicate higher liver blood flow X kg-1 body weight and m2 of body surface area in children. The systemic availability of the aerosol was approximately 30% of nominal dose, i.e. the same as in adults. The high clearance and short half-life of budesonide in children are advantageous in reducing the risk of possible systemic side-effects of prophylactic treatment of asthma in childhood.

Severe aortic stenosis in elderly patients.

Clinical and non-invasive findings were compared with catheterisation data in 91 elderly patients (mean 65 years, range 52-78) with suspected severe aortic stenosis requiring operation. Heart catheterisation showed that forty nine patients had a valve area of less than or equal to 0.6 cm2, 36 had a valve area of 0.7 - 1.0 cm2, and six an area of greater than or equal to 1.1 cm2. Coexistent aortic regurgitation was found in 85% of the cases, but severe regurgitation was found in only one patient (1%). Seventy seven per cent of patients had chest pain, 74% had dyspnoea, and 46% had exertional vertigo or syncope. Coronary angiography, which was performed in 77 patients, showed coronary artery disease in 24% of those with a history of angina pectoris and in none of those without. All patients had echodense valves; aortic valve calcification was shown by x ray in 76% and in all but one by cineradiography. The peak of the systolic murmur was delayed in 98% of the patients. Although a prolonged left ventricular ejection time was characteristic of severe aortic stenosis, a normal value did not exclude this diagnosis. Most patients (84%) had increased QRS amplitude on the electrocardiogram. Echocardiography showed an increased left ventricular wall thickness in 90% of the patients in whom it was possible to define the myocardial borders. There was an inadequate blood pressure increase in response to exercise in 82%. In about 25% of the patients the exercise test was at variance with the New York Heart Association classification. Findings suggesting severe aortic stenosis resembled those reported for younger age groups. When most findings point to severe aortic stenosis, the absence of a single symptom or non-invasive sign does not exclude severe aortic stenosis.