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Background: Chronically medically ill patients often need clinical assistance with symptom management, as well as self-care interventions that can help to reduce the impact of bothersome symptoms. Experienced clinicians can help to guide the development of more effective self-care interventions. Objective: To create a consensus-based list of common bothersome symptoms of chronic conditions and of self-care management behaviors recommended to patients by clinicians to reduce the impact of these symptoms. Methods: A two-round Delphi study was performed among an international panel of 47 clinicians using online surveys to identify common and bothersome symptoms and related self-care management behaviors recommended to patients with heart failure, chronic obstructive pulmonary disease, asthma, type 2 diabetes, or arthritis. Results: A total of 30 common bothersome symptoms and 158 self-care management behaviors across the five conditions were listed. Each chronic condition has its own bothersome symptoms and self-care management behaviors. Consensus was reached on the vast majority of recommended behaviors. Conclusions: The list of common bothersome symptoms and self-care management behaviors reflect consensus across four countries on many points but also disagreement on others, and a few recommendations are inconsistent with current guidelines. Efforts to encourage clinicians to recommend effective self-care management behaviors may reduce symptom impact in chronically ill patient populations.(C) 2022 The Author(s). Published by Elsevier Inc. Funding Agencies|Australian Catholic University, Australia

Background: Among Left Ventricular Assist Device (LVAD) implanted patients, body image modifications might occur. Objectives: To explore the associations between sexual functioning, confidence in LVAD technology, personal wellbeing, and body image. Methods: The cross-sectional study included 30 conveniently recruited LVAD implanted patients who completed Body Image Scale, sexual functioning, confidence in LVAD technology, and Personal Wellbeing Index questionnaires. The associations between the research variables were examined with multiple regression analyses. Results: The mean age of the participants was 63 (SD=10), 90% were men. The mean scores were: sexual functioning 2.43 (SD=1.20, range 1-5); confidence in LVAD technology 2.63 (SD=1.04, range 1-5); Well-Being Index 6.61 (SD=1.53, range 0-10); and body image 14.5 (SD=4.17, range 5-20). Sexual functioning (p

BACKGROUND: The assessment of self-care behaviour is important for tailoring care to patients and evaluating the effectiveness of heart failure (HF) disease-management programmes. The European HF Self-care Behaviour (EHFScB) scale is a validated instrument used worldwide. AIM: The purpose of the study was to evaluate psychometric properties of the Hebrew version of the nine-item EHFScB scale in Israeli patients with HF. METHOD: To develop the Hebrew version of the EHFScB scale, forward and back translation was performed. The psychometric evaluation was based on data from 102 patients with HF (mean age 61±12 yr, male 75%, New York Heart Association [NYHA] class II 42% and NYHA class III 51%) included in two cross-sectional studies performed in 2007 and 2015-2017 in an Israeli hospital. Content validity, construct validity, known-groups validity, and discriminant validity were assessed. Reliability was evaluated with internal consistency. RESULTS: Content validity and useability were confirmed by HF experts and patients with HF. Construct validity was tested using factor analysis and two factors were extracted (factor 1: consulting behaviour; factor 2: adherence to the regimen). Known-groups validity testing revealed a significant difference before and after an educational intervention in the total score (n=40 [41.6±23.8] vs [67.6±21.8]; pFunding agencies: Swedish National Science Council [K2013-69X-22302-01-3, 2016-01390]; Swedish National Science Council/Swedish research council for health, working life and welfare (VR-FORTE) [2014-4100]; Swedish Heart and Lung AssociationSwedish Heart-Lung Foundation [E0

We compare the prevalence of somatization in women and men with NCCP in relation to the general Swedish population, analyze the overlap between somatization, cardiac anxiety, and depressive symptoms, and explore variables associated with somatization. A cross sectional design is implemented with data collected between late October 2013 and early January 2014 from 552 patients with NCCP (mean age of 64 ​± ​17 years, 51% women) from four hospitals in southeast Sweden. Somatization was measured with the Patient Health Questionnaire-15, cardiac anxiety with the Cardiac Anxiety Questionnaire, and depressive symptoms with the Patient Health Questionnaire-9. Data were self-reported. The general population consists of 1898 females and 1508 males. Compared to the general population, somatization was significantly (p ​< ​.001) more common in both women and men with NCCP. Women with NCCP had significantly (p ​= ​.003) higher prevalence of somatization than men with NCCP. In patients with NCCP, 12% had only somatization, whereas 39% also reported cardiac anxiety and depressive symptoms. Younger age in women tended to be associated with somatization (OR ​= ​0.98, p ​< ​.073), but also being non-worker (OR ​= ​0.40, p ​= ​.024). In men, somatization tended to be associated with increased healthcare contacts (OR ​= ​1.82, p ​= ​.051). Furthermore, in both women and men, number of co-morbidities (OR ​= ​9.69 p ​< ​.001 and OR ​= ​3.45, p ​= ​.002), cardiac anxiety (OR ​= ​2.93 and OR ​= ​2.09, p ​< ​.001), and depressive symptoms (OR ​= ​8.71 and OR ​= ​4.44, p ​< ​.001) were significantly associated with somatization. Our study demonstrates that somatization is very common among patients with NCCP, especially in women. Patients with NCCP have higher somatization and greater overlap with psychological distress compared to the general population. Funding: The study was funded by the County Council of Östergötland, Sweden (LIO-439131), and the Medical Research of Southeast Sweden (FORSS-475291), but they were not involved in any part of the study.

Context\ud The increasing number of people living with multiple chronic conditions in addition to an index condition has become an international healthcare priority. Health education curricula have been developed alongside single condition frameworks in health service policy and practice and need redesigning to incorporate optimal management of multiple conditions.\ud \ud Aim\ud Our aims were to evaluate current teaching and learning about comorbidity care amongst the global population of healthcare students from different disciplines and to develop an International Comorbidity Education Framework (ICEF) for incorporating comorbidity concepts into health education.\ud \ud Methods\ud We surveyed nursing, medical and pharmacy students from England, India, Italy and Sweden to evaluate their understanding of comorbidity care. A list of core comorbidity content was constructed by an international group of higher education academics and clinicians from the same disciplines, by searching current curricula and analysing clinical frameworks and the student survey data. This list was used to develop the International Comorbidity Education Framework.\ud \ud Results\ud The survey sample consisted of 917 students from England (42%), India (48%), Italy (8%) and Sweden (2%). The majority of students across all disciplines said that they lacked knowledge, training and confidence in comorbidity care and were unable to identify specific teaching on comorbidities. All student groups wanted further comorbidity training. The health education institution representatives found no specific references to comorbidity in current health education curricula. Current clinical frameworks were used to develop an agreed list of core comorbidity content and hence an International Comorbidity Education Framework.\ud \ud Conclusions\ud Based on consultation with academics and clinicians and on student feedback we developed an International Comorbidity Education Framework to promote the integration of comorbidity concepts into current healthcare curricula.

Background: Depression is a common cause of poorer well-being and prognosis in patients with cardiovascular disease (CVD). Yet there is a lack of effective intervention strategies targeting depression. We therefore evaluated the effect of a nurse-delivered and tailored internet-based cognitive behavioural therapy (iCBT) programme aimed at reducing depression in patients with CVD. Methods: A randomised controlled trial. Patients were recruited from medical or cardiology clinics at five hospitals in south-eastern Sweden. Patients were eligible if they were ≥18 years old, had CVD treatment, had not been hospitalised for CVD in the past four weeks, and had at least mild depressive symptoms. 144 patients were randomised 1.1 to nine-week iCBT (n=72) or an active control participating in an online discussion forum (ODF, n=72) with a block size of two. The primary outcome, depression, was measured by the Patient Health Questionnaire-9. Outcomes: In total, 65 patients in the iCBT group and 62 patients in the ODF completed the outcome measure. Using intention to treat analysis, iCBT compared to ODF had a moderate treatment effect on depression (mean group difference -2·34 [95 % CI -3·58 to -1·10], p=0·0003, effect size d=0·62). No patients were discontinued from the study due to high risk of suicide or deterioration in depression. Interpretation: Nurse-delivered iCBT can reduce depression in CVD patients enabling treatment for depression in their own homes and at their own preferences of time. Trial Registration Number:The trial is registered at ClinicalTrials.gov, NCT02778074. Funding Statement: This study received funding from the Swedish Research Council (2015-02600), ALF grants Region Ostergotland (LIO-600321 and LIO-687531) and Region Ostergotland, Strategic fund (LIO-719561). Declaration of Interests: None of the authors declare any competing interest. Ethics Approval Statement: The study was approved by the regional ethical review board in Linkoping Sweden (no. 2016/72-31).

Background: Vitamin D (Vit D) is suggested to play a role in the regulation of physical function as well as in depression. Since, Vit D deficiency is common in patients with heart failure (HF), this study aims to explore if Vit D levels are associated with depressive symptoms and if this association is mediated by the patients' physical function.Method: 506 HF patients (mean age 71, 38% women) were investigated. Depressive symptoms and physical function were measured with the Centre for Epidemiological Studies Depression Scale and the physical function scale from the RAND-36. Vit D was measured in blood samplesResults: At baseline there was no relationship between depressive symptoms and Vit D levels. However, at 18 months follow-up 29% of patients with Vit D 50 nmol/l (p Conclusion: In HF patients with Vit D 50 nmol/l. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background: To contribute to the protocol development of exercise training in LVAD supported patients by reviewing the exercise programs for those patients in the ESC affiliated countries. Methods: A subset of data from 77 (26 countries) LVAD implanting centers that participated in the Extra-HF survey (170 centers) was analyzed. Results: Of the 77 LVAD implanting centers, 45 (58%) reported to have a functioning exercise training program (ETP) for LVAD patients. In 21 (47%) of the 45 ETP programs in LVAD implanting centers, patients begin their ETP during their in-hospital post-operative recovery period. Most centers (71%) have an early post-discharge program for their patients, and 24% of the centers offer a long-term maintenance program. The professionals involved in the ETPs are mainly physiotherapists (73%), psychologists, cardiac rehab nurses (22%), or cardiologists specialized in rehabilitation (22%). Not all programs include the treating cardiologist or surgeons. Most of the ETPs (84%) include aerobic endurance training, mostly cycling (73%), or walking (62%) at low intensity intervals. Some programs apply resistance training (47%), respiratory muscle training (55%), or balance training (44%). Reasons for the absence of ETPs are referral of patients to another center (14 centers) and lack of resources (11 centers). Conclusion: There is a great variance in ETPs in LVAD implanting centers. Not all the implanting centers have an ETP, and those that do have adopted a local protocol. Clear guidance on ETP supplied by LVAD implanting centers to LVAD supported patients and more evidence for optimal modalities are needed. (C) 2015 Elsevier Ireland Ltd. All rights reserved. Funding Agencies|Heart Failure Association of the ESC

Background and objective: The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field. Method: During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research. Results: In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components. Conclusion: Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each others work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care. (C) 2020 The Authors. Published by Elsevier Ltd. Funding Agencies|Australian Catholic University; National Institutes of Health/National Institute for Nursing Research (NINR) [R01NR018196]; Swedish National Science Council/Swedish Research Council for Health, Working Life and Welfare (VR-FORTE); Center of Excellence for Nursing Scholarship

Purpose Left Ventricular Assist Devices (LVADs) support the diseased heart of patients with advanced heart failure (HF), and are used as a bridge to heart transplantation (HTx), or as a destination therapy for patients ineligible for HTx. LVADs are known to have a major impact on body image and sexual function, however data are still scarce. The purpose of the current study was to investigate the relationship between sexual functioning ability, confidence in LVAD technology, personal wellbeing and body image among LVAD implanted patients. Methods In this cross-sectional correlational study, a convenience sample of 30 adult LVAD implanted patients (mean age 63 ± 10, 90% male) from the outpatient facility of a tertiary medical center, completed questionnaires concerning Sexual Functioning Ability, Confidence in LVAD Technology, Personal Wellbeing Index, and Body Image Scale. Results were analyzed for correlation by multivariate linear regression. Results Seventeen (57%) patients had below average sexual functioning ability scores, 13 (43%) scored below average on confidence in LVAD technology, 11 (37%) had below-average personal wellbeing scores, and 14 (47%) had below-average body image scores. Sexual functioning ability (t=3.35, p Conclusion Sexual functioning and confidence in LVAD technology were independently related to body image among LVAD implanted patients. The current results may help to heighten the awareness of health care providers to the importance of considering a broad range of factors that are related to LVAD implanted patient outcomes.

Objective: The aim was (1) to describe the development of a guided internet-based CBT (ICBT) program adapted to patients with heart failure (HF) and (2) to evaluate the feasibility of the ICBT program in regard to depressive symptoms, the time used by health care providers to give feedback, and participants’ perceptions of the ICBT program. Method: A multi-professional team developed the program and seven HF patients with depressive symptoms were recruited to the study. The Patient Health Questionnaire-9 (PHQ-9) and the Montgomery Åsberg Depression Rating-Self-rating scale (MADRS-S) were used to measure depression, and patients were interviewed about their perceptions of the program. Results: Based on research in HF and CBT, a nine-week program was developed. The median depression score decreased from baseline to the end of the study (PHQ-9: 11–8.5; MADRS-S: 25.5–16.5) and none of the depression scores worsened. Feedback from health care providers required approximately 3 h per patient. Facilitating perceptions (e.g. freedom of time) and demanding perceptions (e.g. part of the program demanded a lot of work) were described by the patients. Conclusion: The program appears feasible and time-efficient. However, the program needs to be evaluated in a larger randomized study.

Objectives: To examine costs and effects of care based on comprehensive geriatric assessment (CGA) provided by an ambulatory geriatric care unit (AGU) in addition to usual care. Design: Assessor-blinded, single-center randomized controlled trial. Setting: AGU in an acute hospital in southeastern Sweden. Participants: Community-dwelling individuals aged 75 years or older who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion and randomized to the intervention group (IG; n ¼ 208) or control group (CG; n ¼ 174). Mean age (SD) was 82.5 (4.9) years. Intervention: Participants in the IG received CGA-based care at the AGU in addition to usual care. Outcome measures: The primary outcome was number of hospitalizations. Secondary outcomes were days in hospital and nursing home, mortality, cost of public health and social care, participant’ sense of security in care, and health-related quality of life (HRQoL). Results: Baseline characteristics did not differ between groups. The number of hospitalizations did not differ between the IG (2.1) and CG (2.4), but the number of inpatient days was lower in the IG (11.1 vs 15.2; P ¼.035). The IG showed trends of reduced mortality (hazard ratio 1.51; 95% confidence interval [CI] 0.988e2.310; P ¼.057) and an increased sense of security in care interaction. No difference in HRQoL was observed. Costs for the IG and CG were 33,371£ (39,947£) and 30,490£ (31,568£; P ¼ .432). Conclusions and relevance: This study of CGA-based care was performed in an ambulatory care setting, in contrast to the greater part of studies of the effects of CGA, which have been conducted in hospital settings. This study confirms the superiority of this type of care to elderly people in terms of days in hospital and sense of security in care interaction and that a shift to more accessible care for older people with multimorbidity is possible without increasing costs. This study can aid the planning of future interventions for older people. Trial Registration: clinicaltrials.gov identifier: NCT01446757. 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered.To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia.Cross-sectional, observational study.In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States.A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions.Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores.There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters.Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.

Background: Thirst is often increased in patients with heart failure (HF) and can cause distress during the course of the condition. The aim of the present study was to describe the trajectory of thirst during an 18-month period and to identify variables associated with persistent thirst in patients with HF.Methods and Results: Data were collected from 649 patients with HF with the use of the Revised Heart Failure Compliance Scale at 1, 6, 12, and 18 months after a period of hospital treatment for worsening HF. Thirst trajectory was described for the 4 follow-up visits and logistic regression analysis was used to identify factors independently associated with persistent thirst. In total, 33% (n = 212) of the patients reported thirst on >= 1 occasions and 34% (n = 46) continued to have thirst at every follow-up visit. Nineteen percent (n = 121) of the patients had persistent thirst. Patients with persistent thirst were more often younger and male and had more HF symptoms. Higher body mass index and serum urea also increased the risk of persistent thirst.Conclusions: Patients with HF who were thirsty at the 1-month follow-up were more often also thirsty at subsequent visits. Assessment of thirst is warranted in clinical practice because one-fifth of patients suffer from persistent thirst.

Background Acute decompensated heart failure (ADHF) is associated with a high rate of readmissions and mortality. Remote dielectric sensing (ReDS) fluid monitoring provides an accurate tool for non-invasive measurement of absolute lung fluid content, providing actionable information and a new tool for managing HF. Methods The SMILE trial was a prospective, multicenter, randomized clinical trial testing the hypothesis that post-discharge HF management guided by frequent in-home ReDS assessment is superior to usual care. Patients with a current hospitalization for ADHF, regardless of the LVEF, were enrolled in 43 US centers. Subjects randomized to the treatment arm were discharged home with the ReDS fluid monitor system and managed using ReDS measurements, according to protocol-defined algorithms. Control patients received usual care, without ReDS. The primary endpoint was recurrent (cumulative) ADHF hospitalizations, analyzed using the Andersen-Gill model with treatment group as the only covariate. Patients were followed for up to 9 months, until the last patient enrolled reached 3 months of follow-up. Results Between October 2015 and October 2017, 268 patients were randomized - 135 to treatment and 133 to control - and followed for 6.1±3.4 months. Patients were aged 68±12 years; 30% were women and 29% had LVEF≥40%. Pre-specified analysis of the per-protocol cohort demonstrated 21 readmissions in 15 ReDS patients compared to 43 readmissions in 34 control patients (HR 0.52, 95% CI [0.31-0.87], P=0.01) or a 48% readmissions reduction (Figure). Subgroup analysis by LVEF Conclusions The SMILE trial demonstrates a substantial reduction in recurrent ADHF hospitalizations and improvement in other outcome measures in recently discharged ADHF patients managed using daily ReDS assessment of absolute lung fluid content.

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Sexual assessment and counselling is a recommended, yet underprovided and challenging, aspect of cardiac rehabilitation. We compared the views of cardiac healthcare providers and patients in terms of their experiences of communication about sexual issues.Cardiac patients (n=382) completed telephone surveys and hospital cardiac rehabilitation staff (n=60) and general practitioners (n=61) returned postal questionnaires.Patients reported that sex was rarely discussed, yet nearly half of patients said they would have liked this opportunity. Most general practitioners (70%) reported not addressing sex with their patients and the majority of cardiac rehabilitators (almost 61%) reported that sexual problems were poorly addressed in their service. Patients perceived fewer barriers to communication (the main barrier was lack of privacy) than health professionals (the primary barrier for general practitioners was lack of time, and for cardiac rehabilitation staff, lack of training).All participants agreed that sexual assessment and counselling is currently poorly implemented. A gap exists: patients, who generally want sexual issues to be addressed, perceive fewer barriers to communication than healthcare providers, who fear causing anxiety and discomfort by raising sexual issues with their patients.Developing brief interventions for healthcare providers and information materials for patients are recommended.

Background: Care of old people with multimorbidity living at home is often fragmented with lack of coordination and information exchange between health care professionals, the elderly and their relatives. This paper describes the protocol of a randomised, controlled study, which aims to compare the efficacy of caring for older people with multimorbidity and three or more hospital admissions in the previous year at a geriatric ambulatory department based on Comprehensive Geriatric Assessment (CGA) versus usual care. Participants and methods: A total of 400 community-dwelling old people with multimorbidity who are living in the city of Norrköping (Sweden) and one of their relatives are recruited for this trial and randomized to an intervention and a control group. Participants in the intervention group receive interdisciplinary care after a CGA at an Ambulatory Geriatric Unit with easy accessibility during working hours in addition to usual care. The control group receives usual care provided by the primary care or hospital. Outcomes: The primary outcome is number of hospitalisation, the secondary outcomes are health-related outcomes including measures of frailty, cognition, symptom burden, feeling of security, quality of life of participants and relatives and as well as costs for health and social care. Participants will be followed for 2 years. Discussion: This study will contribute to evidence of the effect of two different care models. The study has the potential to change care for older people with multimorbidity.

Objectives This study sought to determine the prognostic value of B-type natriuretic peptide (BNP) in patients with heart failure with preserved ejection fraction (HFPEF), in comparison to data in HF patients with reduced left ventricular (LV) EF (Background Management of patients with HFPEF is difficult. BNP is a useful biomarker in patients with reduced LVEF, but data in HFPEF are scarce.Methods In this study, 615 patients with mild to moderate HF (mean age 70 years, LVEF 33%) were followed for 18 months. BNP concentrations were measured at baseline and were related to the primary outcome, that is, a composite of all-cause mortality and HF hospitalization, and to mortality alone. The population was divided in quintiles, according to LVEF, and patients with reduced LVEF were compared with those with HFPEF.Results There were 257 patients (42%) who had a primary endpoint and 171 (28%) who died. BNP levels were significantly higher in patients with reduced LVEF than in those with HFPEF (p Conclusions BNP levels are lower in patients with HFPEF than in patients with HF with reduced LVEF, but for a given BNP level, the prognosis in patients with HFPEF is as poor as in those with reduced LVEF. (J Am Coll Cardiol 2013;61:1498-506) (C) 2013 by the American College of Cardiology Foundation

Background: Identifying patients with heart failure (HF) who are at risk of experiencing symptomatic adverse drug events (ADEs) is important for improving patient care and quality of life. Several demographic and clinical variables have been identified as potential risk factors for ADEs but limited knowledge is available on the impact of HF patients' beliefs and perceptions on their experience of ADEs.Objective: The purpose of the study was to identify the relationship between HF patients' illness perception and medication beliefs and self-reported ADEs.Design: A cross-sectional survey was performed between November 2008 and March 2009.Settings: One university medical centre, two regional hospitals and 20 general practitioners in the Netherlands participated in the study.Participants: 495 patients with HF were included.Methods: Patients completed the validated Revised Illness Perception Questionnaire (IPQR) and the Beliefs about Medication Questionnaire (BMQ) which collected data on their illness perception and medication beliefs. In addition, data on ADEs as experienced in the previous four weeks were collected through an open-ended question and a symptom checklist. Multivariate logistic regression was performed to identify factors associated with these ADEs.Results: In total, 332 (67%) patients had experienced ADEs in the previous four weeks, of whom 28% reported dry mouth, 27% dizziness and 19% itchiness as the most prevalent. In the adjusted multivariate analysis, disease-related symptoms (illness identity) (OR for 1-5 symptoms 3.57: 95% CI 2.22-5.75, OR for >5 symptoms 7.37; 95% CI 3.44-15.8), and general beliefs about medication overuse (OR 1.07; 95% CI 1.01-1.13) were independently associated with experiencing ADEs, whereas none of the demographic or clinical factors were significant.Conclusions: HF patients who perceive a high number of disease symptoms and have negative medication beliefs are at higher risk of experiencing self-reported ADEs. We suggest that future studies and interventions to improve ADE management should focus on negative medication beliefs and assisting patients in differentiating disease symptoms from ADEs. (C) 2011 Published by Elsevier Ltd.

Background: Effective self-care is the cornerstone of the successful management of heart failure (HF). The European Heart Failure Self-care Behaviour Scale is a brief, reliable and valid scale to measure this important construct among patients with HF. Although the EHFScBS has been translated to different languages, no Chinese version is available. Indeed, previous findings investigating the psychometric properties of EHFScBS indicated ambiguity of the conceptual structure of this scale. Aim: The aim of this study was to translate the European Heart Failure Self-care Behaviour Scale (EHFScBS) into Chinese and to test its psychometric properties in the Chinese patients with HF. Methods: The EHFScBS (English Version) was translated to Chinese using Brislin's forward and backward translation method. Panel review was used to examine its semantic equivalence and content validity. The EHFScBS (Chinese Version) was then tested with a convenience sample of 143 Chinese HF patients who attended a specialist clinic from January to September 2007. Results: The content validity index (CVI) of the EHFScBS (Chinese version) was satisfactory (Item CVI = 0.96; Scale CVI = 0.89), with Cronbach's alpha 0.82. Convergent validity was supported by a moderate relationship, statistical significant with a measure for social support (r = −0.36, p < 0.001). However, the findings did not support the hypothesised three-factor structure of the EHFScBS (Chinese Version). Instead, all items except one fit well a two-factor structure to measure help-seeking and regimen-complying behaviours. Conclusion: The adequate psychometric properties and clear conceptual structure of EHFScBS (Chinese Version) warrant its use in Chinese patients with HF.

Objectives Our aim was to study the possible role of depressive symptoms in the effectiveness of a disease management program (DMP) in heart failure (HF) patients. Background Disease management programs are recommended in current HF guidelines, but certain patient groups, such as those with depression, might be less responsive to such programs. Methods From the data of a large multicenter study, in which we examined the effect of a DMP in HF patients, we investigated a potential interaction between depressive symptoms at baseline and the effect of such a program. Results Of the 958 HF patients (37% female; age 71 +/- 11 years; New York Heart Association functional class II to IV), 377 (39%) reported depressive symptoms at baseline. During 18 months of follow-up, the primary end point (composite of all-cause mortality and HF readmission) occurred in 39% of the nondepressed patients and 42% of depressed patients. In the overall sample, there was no significant effect of DMP on the composite primary end point. The effect of the DMP was significantly different in nondepressed than in depressed HF patients. A significant effect modification by depressive symptoms was observed in evaluating the effect of the DMP on all-cause mortality and HF readmission (p = 0.03). In patients without depressive symptoms, DMP resulted in a trend for lower incidence of the primary end point (hazard ratio: 0.8, 95% confidence interval: 0.61 to 1.04), whereas the reverse was observed in patients with depressive symptoms (hazard ratio: 1.3, 95% confidence interval: 0.95 to 1.98). Conclusions Depressive symptoms in patients with HF have a major effect on the usefulness of DMP. Identification of depressive symptoms before enrollment in a DMP might lead to more accurate use of a DMP, because depressive patients might not benefit from a general program. (Netherlands Heart Foundation Coordinating study evaluating Outcomes of Advising and Counselling in Heart Failure; ISRCTN98675639) (J Am Coll Cardiol 2010; 55: 1837-43) (C) 2010 by the American College of Cardiology Foundation

OBJECTIVE: Boussignac continuous positive airway pressure (BCPAP) delivered by face mask is useful for patients with acute cardiogenic Pulmonary edema (ACPE). Although BCPAP is medically effective, we observed that not 611 suitable patients received it. In this descriptive, prospective, cohort study, we explored the experiences and attitudes of both patients and staff with BCPAP.METHODS: Patients were interviewed 12 to 48 hours after treatment with BCPAP. Nurses on the coronary care unit were interviewed on their knowledge, skills, experiences, and opinions concerning BCPAP.RESULTS: Of 117 patients with ACPE, 87 patients (74%) received BCPAP treatment. It was decided not to administer BCPAP in 30 patients with ACPE (26%). Patients who received BCPAP found that the reduction of dyspnea outweighed any discomfort. Barriers for the use of BCPAP were not related to nurses' skills but to the following: the nurses' belief that BCPAP created major discomfort, the lack of guidelines, the ultimate improvement of oxygenation without BCPAP, and the more labor-intensive treatment.CONCLUSION: Overestimation of patient discomfort by nurses and system-related factors impeded the use of BCPAP for all patients with ACPE. (Heart Lung (R) 2008;37:449-454.)

Background--Biomarkers may help us to unravel differences in the underlying pathophysiology between heart failure (HF) patients with a reduced ejection fraction (HFrEF) and a preserved ejection fraction (HFpEF). Therefore, we compared biomarker profiles to characterize pathophysiological differences between patients with HFrEF and HFpEF. Methods and Results--We retrospectively analyzed 33 biomarkers from different pathophysiological domains (inflammation, oxidative stress, remodeling, cardiac stretch, angiogenesis, arteriosclerosis, and renal function) in 460 HF patients (21% HFpEF, left ventricular ejection fraction ≥45%) measured at discharge after hospitalization for acute HF. The association between these markers and the occurrence of all-cause mortality and/or HF-related rehospitalizations at 18 months was compared between patients with HFrEF and HFpEF. Patients were 70.6±11.4 years old and 37.4% were female. Patients with HFpEF were older, more often female, and had a higher systolic blood pressure. Levels of high-sensitive C-reactive protein were significantly higher in HFpEF, while levels of pro-atrial-type natriuretic peptide and N-terminal pro-brain natriuretic peptide were higher in HFrEF. Linear regression followed by network analyses revealed prominent inflammation and angiogenesis-associated interactions inHFpEF and mainly cardiac stretch-associated interactions in HFrEF. The angiogenesis-specific marker, neuropilin and the remodeling-specific marker, osteopontin were predictive for all-cause mortality and/or HF-related rehospitalizations at 18 months in HFpEF, but not in HFrEF (P for interaction < 0.05). Conclusions-In HFpEF, inflammation and angiogenesis-mediated interactions are predominantly observed, while stretchmediated interactions are found in HFrEF. The remodeling marker osteopontin and the angiogenesis marker neuropilin predicted outcome in HFpEF, but not in HFrEF.

s S23 the parameters (speed, pulsatility, power, flow) of the device. Respondents do expect EMS providers understand that patients may be pulseless and they should employ other techniques to determine perfusion such as capillary refill, Doppler-derived blood pressure, color, rhythm and mental status. The complication most frequently discussed is CVA/stroke. Alarm assessment is explained less than half (45.5%) the time and other common complications (infection, GI bleed, right heart failure) are infrequently taught. Conclusion: As the prevalence of CF-LVAD patients in the community grows, the likelihood that EMS providers will care for a CF-LVAD patient increases. Numerous gaps in education have been identified. Opportunities exist to partner with EMS providers to improve education to optimize prehospital care.

Nurses in different settings are involved in caring for patients with heart failure. In the clinic, hospital, nursing home or patients' home, the nurse has a role in detecting, identifying and treating heart failure. In order to provide optimal care, literature on possible and effective interventions should be available to nurses. This study gives an overview of nursing care for patients with heart failure as described in practice, literature and standard nursing care plans. Based on interviews of 45 nurses, a review of all pertinent literature published between 1983 and 1993 and a review of standard nursing care plans used in the Netherlands to care for patients with heart failure, four composite themes emerged; namely, basic nursing care, assessment and observation, symptom-relieving interventions, and patient education. Caring for patients with heart failure is very complex and is often aimed at keeping a very delicate balance between, e.g. rest and activity, fluid intake and elimination, and therapeutic cost and benefit. Treatment strategies for optimizing care for these patients are described.

To determine the effect of low ejection fraction on sexual function and the relation between alterations in sexual function and pertinent clinical, demographic, and psychosocial variables in patients with advanced heart failure.This study was descriptive and correlational in design.The setting was an outpatient clinic of a university-affiliated hospital.Sixty-two male (82%) and female (18%) patients with advanced heart failure (New York Heart Association [NYHA] class III or IV) were studied.Exercise tolerance and symptom severity were assessed by the 6-minute walk and NYHA classification. Ejection fraction was measured by echocardiography. Alterations in the patients' emotional, social, and sexual function were assessed with the self-report version of the Psychosocial Adjustment to Illness Scale.Approximately three quarters of the patients reported a marked decrease in sexual interest and in the frequency of sexual relations caused by illness, with one quarter having ceased all sexual activity. Half the patients described having experienced marked reductions, after heart failure developed, in the pleasure or satisfaction they normally experienced from sex. Few patients had arguments with their spouses about sex or reported significant marital problems as a result of their illness. A significant relation was documented between patients' sexual function and the results of the 6-minute walk (r = 0.32, p0.005), as well as between sexual function and NYHA functional class (r = 0.21, p0.05). Sexual function was also related to the patient's social environment (r = 0.59, p0.001), psychologic distress (r = 0.38, p0.001), and domestic environment (r = 0.29, p0.05). No significant differences in sexual function were noted when patients were compared on the basis of differences in ejection fraction, medications, gender, or age.Advanced heart failure results in marked changes in libido and in the ability to perform sexually. These changes do not affect the marital relationship negatively, at least in the view of the patient. As patients' symptoms of heart failure become increasingly more severe, physicians and nurses need to counsel patients and their spouses about the changes they may experience in their sexual relationships. Attention needs to focus on ways to cope with the decreasing physical status that accompanies advanced heart failure to minimize negative changes in sexual functioning.

Importance: The care of older persons with multimorbidity is a future challenge for the welfare sector in many countries in terms of organization of care and provision of sufficient health care resources. Objective: To determine whether an alternative with an ambulatory geriatric unit (AGU) additional to usual care based on Comprehensive Geriatric Assessment (CGA) is more effective than usual care (UC) only. Design: Randomized, controlled, assessor blinded, single center trial of community dwelling patients ≥75 years, hospitalized at least three times during the past 12 months, having at least three concomitant diagnoses [intervention (AGU) n = 208, control group (UC) n = 175]. Outcomes: Hospitalizations, mortality, health related quality of life (HRQoL) and costs of care. Results: After 24 months there was no difference in number of hospitalizations (2.1 in AGU versus 2.4 in CG (P = 0.19). However, patients in AGU had less inpatient days (11.1) compared to the UC (15.2) (P = 0.03). Further, the UC had 54% higher mortality rate than the IG (HR = 1.54 (95% CI: 1.01-2.34), P = 0.046). The cost of care was € 19,941 in the AGU and € 17,730 in the UC group. There was no difference in HRQoL between the groups. Conclusion: The superiority of the alternative with AGU in important findings such as decreased inpatient days and mortality, but to slightly higher total cost after 24 months follow up. This finding is important knowledge when organizing the care for the elderly. (Less)

Dr. Krumholz and his colleagues are to be congratulated with their effects of a targeted education and support intervention on the rate of readmission or death and hospital cost in patients with heart failure (HF) [(1)][1]. This study adds to the understanding that education and support should be a