The 8th Joint Scandinavian Conference in Cardiothoracic Surgery

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Brynja Ingadottir was an invited speaker at the 8th Joint Scandinavian Conference in Cardiothoracic Surgery  which was held 17-19 August 2016 in Reykjavik Iceland. She presented in the session of SATNU (Scandinavian Association of Thoracic Nurses) about the use of technology in patient education with special focus on the serious game on pain management after surgery which is a part of her Ph.D thesis. The game has been developed in collaboration with Linköping University (Tiny Jaarsma and Ingela Thylén), Reykjavik University, University of Iceland and Landspitali University Hospital, Reykjavik, Iceland.

Nana Waldréus dissertation

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The D-day on the 18th of April 2016 was finally here! D as for dissertation. Four and a half years is quite a long time working hard with your studies and manuscripts. Doing your courses and attending seminars, as well as participating on congresses. Although the work was hard many times, I will always remember these years as so rewarding. Not only that I learned so much, but I also grew as a human being. I thought I had prepared my “mind” for the upcoming defense of my dissertation. When preparing myself the last months, I realized that it is impossible to be prepared for everything. One just has to be in the present moment and trust yourself. So, only two days before the D-day, I went to the EuroHeartCare congress in Athen with CESAR´s, having a doctoral students’ abstract presentation about thirst in patients with heart failure! Being in the present moment.

Professor Anna Forsberg, from Lunds University, was the faculty opponent and did a great work asking me all kinds of relevant and interesting questions about my thesis. The grading committee did also a great work highlighting significant aspects of my research. I was so in the present moment, that when there were no more questions, I realized that three hours had passed! It felt like one hour…. The D-day ended with a nice dinner with my dear friends whom I had the good fortune to get to know during these years!

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My thesis has the title “Thirst in Patients with Heart Failure: Description of thirst dimensions and associated factors with thirst”. The aim of the thesis was to describe the thirst experience of patients with heart failure and describe the relationship of thirst with physiologic, psychologic and situational factors. The goal was to contribute to the improvement of the care by identifying needs and possible approaches to prevent and relieve thirst in patients with heart failure.

The main results of the four studies in the thesis were:

  • Thirst was prevalent in 1 out of 5 patients with stable heart failure
  • 63% of patients with worsening of heart failure symptoms experienced moderate to severe thirst distress at hospital admission
  • Thirst intensity was significantly higher in patients hospitalized with decompensated heart failure compared to patients with no HF (median 75 vs. 25 mm, visual analogue scale [VAS] 0-100 mm; P < 0.001)
  • Patients at an outpatient heart failure clinic who reported thirst at the first visit were more often thirsty at the follow-up visits compared to patients who did not report thirst at the first visit
  • Patients with heart failure who were admitted to the hospital with high thirst distress continued to have high thirst distress over time
  • Patients with heart failure who had a fluid restriction had high thirst distress over time
  • Patients with heart failure who were feeling depressed had high thirst intensity over time
  • Thirst was associated with fluid restriction, a higher serum urea, and depressive symptoms


In conclusion, patients with heart failure experience thirst intensity and thirst distress. Nurses should ask patients with heart failure if they are thirsty and measure the thirst intensity and thirst distress, and ask if thirst is bothering them. Each patient should be critically evaluated if a fluid restriction really is needed, if the patient might be dehydrated or needs to be treated for depression.

The thesis can be accessed at


Nana Waldréus, PhD, RN




A short report from the 18th Cardiovascular Spring Meeting, Gothenburg – 2016

This year’s spring meeting had a great attendance with about 1500 persons. The program was composed by a rich number of interesting sessions, free lectures, posters and research projects. A new prize was also given out “Mona Schlyter clinical prize”.

The Werkö lecture: “Taking the congestion out of heart failure” was held by Prof Lynne Warner Stevenson from Boston, USA. Here main point was that congestion is a central feature of HF. Readmission of patients with HF is common, about 50% seeks hospitals for worsened HF. Studies have showed that RV diastolic pressure is central prior an event and monitoring pressure could might be a better indicator than weight to predict hospitalizations.

Session: Secondary prevention in cardiovascular diseases
Joep Perk, Kalmar. A new secondary prevention model for IHD is developed. Five steps are considered to be of importance to reduce the risk for further cardiovascular events. The goal is to have regular follow up the first year and to advice patients to stop smoking, be physical active and eat health food, be careful with alcohol and keep blood pressure under 140/90 mmHg. LDL-kolesterol should be lower than 1,8 mmol/l. If patient succeed, the best points will be 5.

Session: A paradigm shift in the treatment of heart failure
Lars Lund, Stockholm gave an inspiring talk about Sakubitril/valsartan (Entresto). This is a new combination medicine for use in heart failure that decrease both mortality and morbidity up to 20%.
Treatment will be given to those who follow the criteria for the study population.

Sessions: Heart failure in elderly, what to do when there is lack of evidence?
Kurt Boman, Skellefteå held a speech about what guidelines tells about acute HF in elderly. In fact, as most studies in HF has been done in people under 75 there is no evidence for how to treat elderly with HF. Guidelines describes briefly that it is important to take age, comorbidity in considering in HF treatment. Kurt says that it is challenge to extrapolate data from younger to older patients and that we need studies that are designed for elderly patients’ as well.

Session: Challenge of adherence to treatment of heart failure
Tiny Jaarsma, Linköping talked about technology in heart failure and that technology are an important source for self-care management. Carina Hjelm, Linköping talked about the importance of cognition in heart failure.

Session: Technology to improve self-care management
Maria Liljeroos, Linköping held a speech about the website in which help patients’ with heart failure to get fast and clear self-care advice.
Leonie Klompstra, Norrköping visualized that Gamification help patients with heart failure to be more active and thereby having better outcomes. Please visit the website
Congrats to all of you who awarded prizes!

  • The Fridlunds prize was given to Peter Johansson, Linköping
  • Mona Schlyter prize was given to Nina Lahti, Stockholm for the project to optimize the care for patients with heart failure.
  • Ulla Walfridsson, Linköping awarded prize for best free lecture and got also travel grants from The Swedish Heart Association travel grants.


Some of the Cesar members standing from left:
Carina Hjelm, Leonie Klompstra, Maria Liljeroos, Christina Andreae


More information about the spring meeting is available by

Written by Christina Andreae

EuroHeartCare 2016 in Athens


Many Cesars participated in this year’s Congress, both with posters and presentations.


Why is it so difficult to talk about prognosis? T. Jaarsma (Norrkoping, SE)


How can we best deliver effective cardiac rehabilitation for people with Heart Failure. M. Back (Gothenburg, SE)

Managing the challenge of polypharmacy in heart failure patients for further development. M. Liljeroos (Eskilstuna, SE)


Arrhythmia: nurse-led management. J. M. L. Hendriks (Sittard, NL)


Fluid restriction predicts thirst distress in patients with heart failure. N. Waldreus, M.H.L. Van Der Wal, M.L. Chung, T. Jaarsma (Linkoping, SE; Groningen, NL; Lexington, US)


To telemonitoring or not to telemonitor: that is the question. Underlying thoughts from nurses and physicians in Japan and Sweden.N. Kato, P. Johansson, I. Okada, K. Kinugawa, A. Stromberg, T. Jaarsma (Linkoping, SE; Tokyo and Toyama, JP)

Participation in the care encounter among patients with heart failure receiving home-care. L. Nasstrom, J. Martensson, E. Idvall, A. Stromberg (Linköping, Jönköping and Malmö, SE)


Patients and caregivers symptoms of depressive symptoms mediate the relationship between perceived control and well-being. M. Liljeroos, A. Stromberg, M. Chung (Linkoping, SE; Lexington, US)

Using co-design to develop communication interventions in heart failure care. A.-L. Hjelmfors, A.S. Stromberg, M.F. Friedrichsen, A.S. Sandgren, J.M. Martensson, T.J. Jaarsma (Linkoping, Kalmar and Jonkoping, SE)

Octo-nonagenerians outlook on life and death when living with an implantable cardioverter defibrillator. A cross-sectional study. I. Thylen, A. Stromberg, D. Moser (Linköping, SE; Lexington, US)

Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain a pilot randomized controlled study. G. Mourad, A. Stromberg, E. Jonsbu, M. Gustafsson, P. Johansson, T. Jaarsma (Norrköping and Linköping, SE; Molde, NO)

The virtual Swedish bowling competition. T.J. Jaarsma, L.K. Klompstra, L.H. Hjelmfors, A.S. Stromberg (Linkoping, SE)

Exploring partners’ perspectives on participation in heart failure home-care – a mixed method design. L. Nasstrom, M.L. Luttik, E. Idvall, A. Stromberg (Linköping and Malmö, SE; Groningen, NL)

Do patients and caregivers perceived control impact depression and well-being in patients with heart failure and partners? M. Liljeroos, K.A. Arestedt, A.S. Stromberg, M.C. Chung (Uppsala and Linkoping, SE; Lexington, US)

Self-efficacy, motivation and physical activity in heart failure patients. L. Klompstra, T. Jaarsma, A. Stromberg (Norrkoping and Linkoping, SE)

Disease severity is related to psychosocial distress in chronic heart failure patients, but not in caregivers: results from an observational study. A. Stromberg, M.L. Chung, T. Jaarsma, M.L. Luttik, E. Lewis, F. Calado, R. Lahoz, E. Hudson, C. Deschaseaux (Linkoping, SE; Lexington and Boston, US; Groningen, NL; Basel, CH; Dublin,IE)


Cesar Network hope to see you all in Jönköping next year!

Tiny Jaarsma as Adjunct Visiting professor at Mary MacKillop Institute for Health Research, ACU, Melbourne

Since June 2105 I have been appointed at the Mary MacKillop Institute for Health Research as Adjunct Visiting professor. The Mary MacKillop Institute aims to identify critical gaps within community and healthcare services, with an explicit goal to improve health outcomes via innovative individual, community and health service-focused programs.

In this collaboration I work together with researchers in different areas, expanding on my current research that I perform at LiU and exploring new fields of research collaboration. This collaboration takes place during regular visits and also more virtual contacts, like skype and email. During a recent visit in March 2016 I presented my work in a lunchtime symposium ( : During the same visit I also presented on the anniversary celebration where the impressive work of the institute was presented. Here on the picture I pose as international jury member (with dr M Piano from the US and dr ML Lochen from Norway) and 2 prize winners of the best research idea.


The Mary MacKillop Institute has different active institutes that perform research in a lot of areas related to the subject the CESAR- network members are involved. I hope that we can set up an exchange between our groups in the near future.



Scholar visit at University of California, Irvine 9-21 March 2016


For my last article of my dissertation I visited my second supervisor, Anna Strömberg, to learn more about qualitative content analysis.

This University of Calafornia Irvine was founded in 1965 and unlike most other University of California campuses, UCI was not named at the city it was built in, but after James Irvine, a landowner. The city Irvine is later built around the campus (see picture below).



Anna Strömberg and me worked for almost 2 weeks very close together to analyze interviews within the HF-Wii study ( on experiences of patients with heart failure in exergaming.

At the end of my visit we made a first draft of the article and I learned a lot about qualitative research and analyzing interviews.

Outside of work we also participated in whale watching: where we saw whales, dolphins, sea lions and seals (see pictures below).


We also had a great medieval dinner party (see pictures below) on invitation of professor Lorraine S. Evangelista.


The two weeks were really great and I learned a lot! Therefore I also want to thank Anna Strömberg, her family (Tomas, David and especially Jonatan for learning me the American way) and Lorraine Evangelista.
//Leonie Klompstra

Ghassan Mourad dissertation



Friday the 4th of December 2015 was the day I had been preparing for…for several year. This was the day for my dissertation. The day when I had to defend all the work I had performed during my doctoral studies. It was with mixed emotions that I looked forward to this day. From being far away it was suddenly time to roll up my sleeves and tackle the trickiest part of the doctoral studies.

The faculty opponent, Siv Söderberg, and the grading committee did a great job and made me feel that I had done a great piece of work. I really enjoyed discussing my thesis with all of them and I felt a bit disappointed when time was over…not really what I thought that I would feel. Off-course, passing this exam felt great and was a huge success. Looking back at it, dissertation day was a really good day that ended with a great party. I shared it with close friends and colleagues. This day was filled with a lot of nice speeches, song and dance performances, and I received a lot of nice gifts. It was a real ego boost hearing a lot of nice words about yourself, wow I could do that again!

Here is a short summary of my thesis:

This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. In study I, 267 patients participated. Out of these, 199 patients participated in study II. Participants in these studies were predominantly male (about 60 %) with a mean age of 67 years. Study III had a cross-sectional explorative and descriptive design including 552 patients (51 % women, mean age 64 years). Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years. The intervention group received a four-session guided Internet-delivered cognitive behavioural therapy (CBT) and the control group received usual care.

The overall aim of this thesis was to improve care for patients with non-cardiac chest pain (NCCP) by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention.

The specific aims for the four studies were:

Aim I: To compare depressive symptoms and healthcare utilization in patients admitted for later proven NCCP, compared to patients with ischemic heart disease presenting with acute myocardial infarction (AMI) and angina pectoris (AP) during a 1-year follow-up after an acute chest pain event.

Aim II: To present a detailed description of the costs of patients with NCCP compared to patients with AMI and AP from a societal perspective.

Aim III: To explore the prevalence of depressive symptoms, cardiac anxiety, and fear of body sensations in patients who were admitted to hospital because of chest pain and discharged with a NCCP diagnosis. Further, we aimed to describe how depressive symptoms, cardiac anxiety and fear of body sensations are related to each other and to healthcare-seeking behavior.

Aim IV: To test the feasibility of a short guided Internet-delivered CBT intervention and the effects on chest pain, cardiac anxiety, fear of body sensations, and depressive symptoms in patients with NCCP compared to usual care.

The main findings were that patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. The short guided Internet-delivered CBT program seemed to be feasible and was perceived as easy to manage, with comprehensible language, adequate and varied content, and manageable homework assignments. Patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain.

You can access the whole framework at Please do not hesitate to contact me in case of any queries.

Thank you for your attention.

Ghassan Mourad, PhD, RN