IgG hexamers initiate complement-dependent acute lung injury

Antibodies can initiate lung injury in a variety of disease states such as autoimmunity, transfusion reactions, or after organ transplantation, but the key factors determining in vivo pathogenicity of injury-inducing antibodies are unclear. Harmful antibodies often activate the complement cascade. A model for how IgG antibodies trigger complement activation involves interactions between IgG Fc domains driving assembly of IgG hexamer structures that activate C1 complexes. The importance of IgG hexamers in initiating injury responses was unclear, so we tested their relevance in a mouse model of alloantibody and complement-mediated acute lung injury. We used three approaches to block alloantibody hexamerization (antibody carbamylation, the K439E Fc mutation, or treatment with domain B from Staphylococcal protein A), all of which reduced acute lung injury. Conversely, Fc mutations promoting spontaneous hexamerization made a harmful alloantibody into a more potent inducer of acute lung injury and rendered an innocuous alloantibody pathogenic. Treatment with a recombinant Fc hexamer 'decoy' therapeutic protected mice from lung injury, including in a model with transgenic human FCGR2A expression that exacerbated pathology. These results indicate an in vivo role of IgG hexamerization in initiating acute lung injury and the potential for therapeutics that inhibit or mimic hexamerization to treat antibody-mediated diseases.

IgG hexamers initiate acute lung injury

Antibodies can initiate lung injury in a variety of disease states such as autoimmunity, transfusion reactions, or after organ transplantation, but the key factors determining in vivo pathogenicity of injury-inducing antibodies are unclear. A previously overlooked step in complement activation by IgG antibodies has been elucidated involving interactions between IgG Fc domains that enable assembly of IgG hexamers, which can optimally activate the complement cascade. Here, we tested the in vivo relevance of IgG hexamers in a complement-dependent alloantibody model of acute lung injury. We used three approaches to block alloantibody hexamerization (antibody carbamylation, the K439E Fc mutation, or treatment with domain B from Staphylococcal protein A), all of which reduced acute lung injury. Conversely, Fc mutations promoting spontaneous hexamerization made a harmful alloantibody into a more potent inducer of acute lung injury and rendered an innocuous alloantibody pathogenic. Treatment with a recombinant Fc hexamer 'decoy' therapeutic protected mice from lung injury, including in a model with transgenic human FCGR2A expression that exacerbated pathology. These results indicate a direct in vivo role of IgG hexamerization in initiating acute lung injury and the potential for therapeutics that inhibit or mimic hexamerization to treat antibody-mediated diseases.

Modulation of Neutrophil Function by Recombinant Human IgG1 Fc Hexamer in the Endogenous K/BxN Mouse Model of Rheumatoid Arthritis

INTRODUCTION

Neutrophils are a pivotal cell type in the K/BxN mouse model of rheumatoid arthritis and play an essential role in the progression of the arthritis. They are readily activated by immune complexes (ICs) via their FcγRs to release IL-1β in addition to other cytokines, which are inducing cartilage destruction. Neutrophils also release neutrophil-active chemokines to recruit themselves in an autocrine manner to perpetuate tissue destruction. FcγR-expression on neutrophils is of crucial importance for the recognition of ICs.

METHODS

In this study, due to its high avidity for binding to FcγRs, we investigated the potential anti-inflammatory effect of a recombinant IgG1 Fc hexamer (rFc-µTP-L309C) on neutrophils in the K/BxN mouse model of endogenously generated chronic arthritis. 200 mg/kg rFc-µTP-L309C and human serum albumin (HSA), used as controls, were administered subcutaneously every other day. Mouse ankle joints were monitored daily to generate a clinical score. Immunohistology was used to evaluate neutrophil infiltration and TUNEL to assess apoptosis. ELISA was used to measure IL-1β.

RESULTS

Treatment with rFc-µTP-L309C, but not HSA, was able to significantly ameliorate the arthritis in the K/BxN mice. Significant neutrophil infiltration into the ankle joint was found, but treatment with rFc-µTP-L309C resulted in significantly less neutrophil infiltration. There was no significant influence of rFc-µTP-L309C on neutrophil death or apoptosis. Less neutrophil infiltration could not be correlated to chemokine-mediated migration. Significantly less IL-1β was measured in mice treated with rFc-µTP-L309C.

CONCLUSION

In the endogenous K/BxN mouse model of rheumatoid arthritis, amelioration can be explained in part by inhibition of neutrophil infiltration into the joints as well as inhibition of IL-1β production. Given the observed inhibitory properties on neutrophils, rFc-µTP-L309C may be a potential therapeutic candidate to treat autoimmune and inflammatory conditions in which neutrophils are the predominant cell type involved in pathogenesis.

Using the K/BxN mouse model of endogenous, chronic, rheumatoid arthritis for the evaluation of potential immunoglobulin-based therapeutic agents, including IVIg and Fc-μTP-L309C, a recombinant IgG1 Fc hexamer

BACKGROUND

High-dose intravenous immunoglobulin (IVIg), and more recently, subcutaneously-delivered Ig (SCIg), are used to treat a variety of autoimmune diseases; however, there are challenges associated with product production, availability, access and efficacy. These challenges have provided incentives to develop a human recombinant Fc as a more potent alternative to IVIg and SCIg for the treatment of autoimmune diseases. Recently, a recombinant human IgG1 Fc hexamer (Fc-μTP-L309C) was shown to be more efficacious than IVIg in a variety of autoimmune mouse models. We have now examined its efficacy compared to IVIg and SCIg in the K/BxN mouse model of endogenous, chronic rheumatoid arthritis (RA).

RESULT

Using the serum-transfer K/BxN model and the endogenous autoimmune model, amelioration of the arthritis was achieved. Effective treatment required high and frequent doses of IVIg, SCIg and Fc-μTP-L309C. However, Fc-μTP-L309C was efficacious at 10-fold lower doses that IVIg/SCIg. Also, arthritis could be prevented when Fc-μTP-L309C was given prior to onset of the arthritis in both the endogenous model and in the serum transfer model.

CONCLUSIONS

Our results show that Fc-μTP-L309C is a powerful treatment for the prevention and amelioration of severe, chronic arthritis in a true autoimmune mouse model of RA. Thus, the K/BxN endogenous arthritis model should be useful for testing potential therapeutics for RA. Our findings provide rationale for further examination of the treatment efficacy of immunoglobulin-based therapeutics in rheumatoid arthritis.

Small-Molecule Immunosuppressive Drugs and Therapeutic Immunoglobulins Differentially Inhibit NK Cell Effector Functions in vitro

Small-molecule immunosuppressive drugs (ISD) prevent graft rejection mainly by inhibiting T lymphocytes. Therapeutic immunoglobulins (IVIg) are used for substitution, antibody-mediated rejection (AbMR) and HLA-sensitized recipients by targeting distinct cell types. Since the effect of ISD and IVIg on natural killer (NK) cells remains somewhat controversial in the current literature, the aim of this comparative study was to investigate healthy donor's human NK cell functions after exposure to ISD and IVIg, and to comprehensively review the current literature. NK cells were incubated overnight with IL2/IL12 and different doses and combinations of ISD and IVIg. Proliferation was evaluated by ³[H]-thymidine incorporation; phenotype, degranulation and interferon gamma (IFNγ) production by flow cytometry and ELISA; direct NK cytotoxicity by standard ⁵¹[Cr]-release and non-radioactive DELFIA assays using K562 as stimulator and target cells; porcine endothelial cells coated with human anti-pig antibodies were used as targets in antibody-dependent cellular cytotoxicity (ADCC) assays. We found that CD69, CD25, CD54, and NKG2D were downregulated by ISD. Proliferation was inhibited by methylprednisolone (MePRD), mycophenolic acid (MPA), and everolimus (EVE). MePRD and MPA reduced degranulation, MPA only of CD56^bright NK cells. MePRD and IVIg inhibited direct cytotoxicity and ADCC. Combinations of ISD demonstrated cumulative inhibitory effects. IFNγ production was inhibited by MePRD and ISD combinations, but not by IVIg. In conclusion, IVIg, ISD and combinations thereof differentially inhibit NK cell functions. The most potent drug with an effect on all NK functions was MePRD. The fact that MePRD and IVIg significantly block NK cytotoxicity, especially ADCC, has major implications for AbMR as well as therapeutic strategies targeting cancer and immune cells with monoclonal antibodies.

rIgG1 Fc Hexamer Inhibits Antibody-Mediated Autoimmune Disease via Effects on Complement and FcγRs

Activation of Fc receptors and complement by immune complexes is a common important pathogenic trigger in many autoimmune diseases and so blockade of these innate immune pathways may be an attractive target for treatment of immune complex-mediated pathomechanisms. High-dose IVIG is used to treat autoimmune and inflammatory diseases, and several studies demonstrate that the therapeutic effects of IVIG can be recapitulated with the Fc portion. Further, recent data indicate that recombinant multimerized Fc molecules exhibit potent anti-inflammatory properties. In this study, we investigated the biochemical and biological properties of an rFc hexamer (termed Fc-μTP-L309C) generated by fusion of the IgM μ-tailpiece to the C terminus of human IgG1 Fc. Fc-μTP-L309C bound FcγRs with high avidity and inhibited FcγR-mediated effector functions (Ab-dependent cell-mediated cytotoxicity, phagocytosis, respiratory burst) in vitro. In addition, Fc-μTP-L309C prevented full activation of the classical complement pathway by blocking C2 cleavage, avoiding generation of inflammatory downstream products (C5a or sC5b-9). In vivo, Fc-μTP-L309C suppressed inflammatory arthritis in mice when given therapeutically at approximately a 10-fold lower dose than IVIG, which was associated with reduced inflammatory cytokine production and complement activation. Likewise, administration of Fc-μTP-L309C restored platelet counts in a mouse model of immune thrombocytopenia. Our data demonstrate a potent anti-inflammatory effect of Fc-μTP-L309C in vitro and in vivo, likely mediated by blockade of FcγRs and its unique inhibition of complement activation.

Recombinant IgG1 Fc hexamers block cytotoxicity and pathological changes in experimental in vitro and rat models of neuromyelitis optica

Intravenous human immunoglobulin G (IVIG) may have therapeutic benefit in neuromyelitis optica spectrum disorders (herein called NMO), in part because of the anti-inflammatory properties of the IgG Fc region. Here, we evaluated recombinant Fc hexamers consisting of the IgM μ-tailpiece fused with the Fc region of human IgG1. In vitro, the Fc hexamers prevented cytotoxicity in aquaporin-4 (AQP4) expressing cells and in rat spinal cord slice cultures exposed to NMO anti-AQP4 autoantibody (AQP4-IgG) and complement, with >500-fold greater potency than IVIG or monomeric Fc fragments. Fc hexamers at low concentration also prevented antibody-dependent cellular cytotoxicity produced by AQP4-IgG and natural killer cells. Serum from rats administered a single intravenous dose of Fc hexamers at 50 mg/kg taken at 8 h did not produce complement-dependent cytotoxicity when added to AQP4-IgG-treated AQP4-expressing cell cultures. In an experimental rat model of NMO produced by intracerebral injection of AQP4-IgG, Fc hexamers at 50 mg/kg administered before and at 12 h after AQP4-IgG fully prevented astrocyte injury, complement activation, inflammation and demyelination. These results support the potential therapeutic utility of recombinant IgG1 Fc hexamers in AQP4-IgG seropositive NMO.

IVIG in autoimmune disease - Potential next generation biologics

Polyclonal plasma-derived IgG is a mainstay therapeutic of immunodeficiency disorders as well as of various inflammatory autoimmune diseases. In immunodeficiency the primary function of IVIG/SCIG is to replace missing antibody specificities, consequently a diverse Fab-based repertoire is critical for efficacy. Attempts to capture the Ig repertoire and express it as a recombinant IVIG product are currently ongoing. Likewise correction of the defective genes by gene therapy has also been tried. However, both approaches are far from becoming mainstream treatments. In contrast, some of the most important effector mechanisms relevant in therapy of autoimmunity are based on the Fc-portion of IgG; they include scavenging of complement and blockade/modulation of IgG receptors (Fc gamma receptor [FcγR] or the neonatal Fc receptor [FcRn]). These effects might be achieved with appropriately formulated Fc-fragments instead of full-length IgG, as suggested by a pilot study with monomeric plasma-derived Fc in children with ITP and in Kawasaki disease in the 1990s. Since then it has been proposed that structured multimerization of Fc fragments might confer efficacy at much lower doses than with IVIG. Accordingly, various molecular strategies are currently being explored to achieve controlled Fc multimerization, e.g. by fusion of IgG1 Fc to the IgG2 hinge-region or to the IgM tail-piece. Safety considerations will be crucial in the evaluation of these new entities. In a different approach, mutant Fc fragments and monoclonal antibodies have been designed for blockade of the FcRn.

A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment

BACKGROUND

Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear.

AIM

To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment.

DESIGN AND METHODS

This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication.

SETTINGS

The study was conducted within four medical wards of an acute care university hospital in urban Switzerland.

PARTICIPANTS

A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively.

RESULTS

Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units.

CONCLUSIONS

The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.

Reconstituted high-density lipoprotein modulates activation of human leukocytes

An anti-inflammatory effect of reconstituted High Density Lipoprotein (rHDL) has been demonstrated in atherosclerosis and in sepsis models. An increase of adhesion molecules as well as tissue factor expression on endothelial cells in response to inflammatory or danger signals are attenuated by the treatment with rHDL. Here we show the inhibitory effect of rHDL on the activation of human leukocytes in a whole blood assay as well as on monocyte-derived human dendritic cells (DC). Multiplex analysis of human whole blood showed that phytohaemagglutinin (PHA)-induced secretion of the cytokines IL-1β, IL-1RA, IL-2R, IL-6, IL-7, IL-12(p40), IL-15 and IFN-α was inhibited. Furthermore, an inhibitory effect on the production of the chemokines CCL-2, CCL-4, CCL-5, CXCL-9 and CXCL-10 was observed. Activation of granulocytes and CD14+ monocytes by PHA is inhibited dose-dependently by rHDL shown as decreased up-regulation of ICAM-1 surface expression. In addition, we found a strong inhibitory effect of rHDL on toll-like receptor 2 (TLR2)- and TLR4-mediated maturation of DC. Treatment of DC with rHDL prevented the up-regulation of cell surface molecules CD80, CD83 and CD86 and it inhibited the TLR-driven activation of inflammatory transcription factor NF-κB. These findings suggest that rHDL prevents activation of crucial cellular players of cellular immunity and could therefore be a useful reagent to impede inflammation as well as the link between innate and adaptive immunity.

[Understanding needs of people with Multiple Sclerosis. Perspective of patients and significant others in the German-speaking part of Switzerland]

Since there is no data available about the needs of people living with Multiple Sclerosis and significant others in Switzerland a questionnaire based cross sectional study was conducted with 878 patients and 615 family caregivers. This Swiss study used the addresses from the Swiss Multiple Sclerosis Society. The response rate was 35.2 % for patients and 70.1 % for significant others. Data analysis included descriptive and inferential statistics. Results showed that information needs are most important followed by consultation. 42.4 % of patients and 39.2  % of family caregivers need more information about alternative treatment options and 34.4 %, resp. 36.6  % about actual research results. For 39.5  % of patients, the possibility of using of their wheelchair in public is insufficient. Approximately a third of patients need more consultation in order to better manage cognitive impairment and fatigue. 30.9 % of family caregivers need more consultations in order to better manage their feelings of burden. Influencing factors of patients' need for consultation about fatigue are health status, quality of life, and anxiety. Patients' need for consultation about their management of cognitive impairment was influenced by health status, medication, and their ability of dealing with constraints and anxiety. The results showed that an enhancement of the quality of treatment and care based on patients' and family caregivers' needs are urgently needed.

The unspoken disease: symptom experience in women with vulval neoplasia and surgical treatment: a qualitative study

Women with vulval neoplasia often experience severe post-surgical complications. This study focuses on symptom experience of women during the first 6 months following surgical treatment for vulval neoplasia considering their socio-cultural context. In this qualitative study using a critical hermeneutic approach, narrative interviews were conducted. A purposeful sample of 20 patients was recruited from one Swiss and two German university hospitals. Content analysis was employed to analyse the transcribed interviews considering women's experiences and social perceptions. Narratives showed eight interrelated themes: delayed diagnosis, disclosed disease, disturbed self-image, changed vulva care, experienced wound-related symptoms, evoked emotions, affected interpersonal interactions and feared illness progression. The women experienced a general lack of information pertaining to above themes and all described strategies used to handle their situation, which affected their distress. The communication, assessment and treatment of symptoms were hampered by the society's and the health system's tendency to overlook these symptoms and leave them in the realm of the unspeakable. Health professionals need new strategies to support these women to recognise, assess and evaluate the seriousness of symptoms, and to communicate their symptom experience so that timely medical treatment is sought. This support may minimise potentially preventable complications and symptom-related distress.

The complement inhibitor low molecular weight dextran sulfate prevents TLR4-induced phenotypic and functional maturation of human dendritic cells

Low molecular weight dextran sulfate (DXS) has been reported to inhibit the classical, alternative pathway as well as the mannan-binding lectin pathway of the complement system. Furthermore, it acts as an endothelial cell protectant inhibiting complement-mediated endothelial cell damage. Endothelial cells are covered with a layer of heparan sulfate (HS), which is rapidly released under conditions of inflammation and tissue injury. Soluble HS induces maturation of dendritic cells (DC) via TLR4. In this study, we show the inhibitory effect of DXS on human DC maturation. DXS significantly prevents phenotypic maturation of monocyte-derived DC and peripheral myeloid DC by inhibiting the up-regulation of CD40, CD80, CD83, CD86, ICAM-1, and HLA-DR and down-regulates DC-SIGN in response to HS or exogenous TLR ligands. DXS also inhibits the functional maturation of DC as demonstrated by reduced T cell proliferation, and strongly impairs secretion of the proinflammatory mediators IL-1beta, IL-6, IL-12p70, and TNF-alpha. Exposure to DXS leads to a reduced production of the complement component C1q and a decreased phagocytic activity, whereas C3 secretion is increased. Moreover, DXS was found to inhibit phosphorylation of IkappaB-alpha and activation of NF-kappaB. These findings suggest that DXS prevents TLR-induced maturation of human DC and may therefore be a useful reagent to impede the link between innate and adaptive immunity.

Flow cytometric analysis on cross-reactivity of human-specific CD monoclonal antibodies with splenocytes of Aotus nancymaae, a non-human primate model for biomedical research

The reactivity of 204 monoclonal antibodies (mAb) out of 377 commercially available antibodies collected by the animal homologue group of the HLAD8 was analyzed by single colour flow cytometry. Most of these mAb were originally developed against human cell surface molecules. Fifty-eight mAb (28%) showed reactivity with spleen cells of Aotus nancymaae, a non-human primate animal model in biomedical research. Out of these 58 mAb, 22 also showed reactivity with mononuclear cells derived from rhesus macaques and cynomolgus monkeys indicating that the epitopes recognized are evolutionary conserved between human, Old and New World monkeys. This novel panel of A. nancymaae reactive mAb will increase the potential to explore complex host-pathogen interactions in non-human primate animal models, particularly in malaria vaccine research.

Starting or changing therapy - a prospective study exploring antiretroviral decision-making

BACKGROUND

When to start or change antiretroviral treatment against HIV infection is of major importance. Patients' readiness is considered a major factor influencing such treatment decisions, in particular because no objective, absolute time point when to start antiretroviral therapy exists. We aimed at evaluating patients' readiness to start or change antiretroviral therapy (ART).

PATIENTS AND METHODS

HIV-infected patients starting or changing ART between July 2002 and February 2003, treating physicians and nurses participated in this prospective, observational multicenter study. We assessed shared decision-making including qualitative aspects, expected treatment decisions and treatment status after 3 months.

RESULTS

75 patients were included. Of 34 patients for whom starting ART was considered, 27 (79%) indicated that they were willing to start treatment. After 3 months, 21 of 27 (78%) actually started therapy, six did not. Patients with depression were less likely to be ready for ART (p < 0.05). Of 41 patients for whom changing ART was considered, 35 (85%) indicated that they were willing to change treatment. Of the latter 35 patients, 33 (94%) finally changed ART within 3 months. Physicians and nurses were too optimistic in predicting the start or change of ART. The main reason to start or change ART was the sole recommendation of the physician (52% in those starting, 61% in those changing ART). Patients mainly judged the decision as shared and were very satisfied (71%) with the process. Qualitative findings revealed the importance of a dialectic decisionmaking, described with two categories: "dealing with oneself and others"' and "understanding and being understood."

CONCLUSION

Patients mainly shared the decision made during consultation. Although physicians have an essential role concerning ART, patients, physicians, and nurses all contribute to the decision. Qualitative findings indicate the importance for health-care providers to include patients' expertise and contributions.

Structural and functional characterisation of the Toll like receptor 9 of Aotus nancymaae, a non-human primate model for malaria vaccine development

In the absence of suitable rodent animal models for Plasmodium falciparum malaria, the efficacy testing of asexual blood-stage vaccine candidates in Aotus nancymaae represents a tool to select between different formulations before conducting expensive human clinical trials. CpG oligonucleotides (ODN) specifically promote the production of pro-inflammatory and Th1-type cytokines and they enhance the immunogenicity of co-administered antigens. Toll like receptor 9 (TLR-9) binds directly and sequence-specifically to single-stranded un-methylated CpG-DNA mediating the biological effects of CpG ODN. We cloned and functionally characterised the TLR-9 cDNA of A. nancymaae. The cDNA encompassed 3,099 bp predicted to code for 1,032 amino acid residues. Results of homology searches to human TLR-9 suggested that the receptor is 93 and 94% identical at the nucleotide and amino acid sequence levels, respectively. Stimulation of splenocytes of A. nancymaae with CpG ODN resulted in proliferative responses in all animals analysed. FACS analysis of cultures incubated with CpG ODN 2006 indicated that the B cell marker CD20 was up-regulated consistent with B cell activation. The high level of sequence conservation of Aona-TLR-9 reinforces the suitability of A. nancymaae as animal model for malaria subunit vaccine development.

[Developing and establishing an expanded and more comprehensive HIV/AIDS nursing practice]

Developing and establishing an advanced nursing practice is an essential step toward future-oriented nursing care. An action research process was initiated to establish advanced nursing practice at the HIV clinic of the outpatient department at the University Hospital Basel with the goal to offer advanced nursing care to patients. Participatory action research allows generating knowledge about a social system while at the same time tempts to promote social change. The most important goal is to constantly analyse, improve, and evaluate nursing care for patients and family caregivers. Advanced nursing practice in HIV/AIDS is based on solid knowledge regarding the illness and current therapies. Central concepts are caring, clinical experiences, evidence based practice, and patient preferences. Through a systematic step-by-step process, the nurses at the HIV clinic are being better educated and more experienced in these concepts. An essential aspect of advanced nursing practice is the specialization of each nurse in a self selected topic within HIV/AIDS care. These nurses now offer new services such as medication management and adherence support, health maintenance and prevention, and symptom management. This ongoing process of learning while establishing advanced nursing practice in HIV/AIDS, enables the nurses to face future changes in health care in a proactive way.

HIV/AIDS family care-giving in Switzerland in the context of silence

Aufgrund einer qualitativen Studie im Rahmen der kritisch-hermeneutischen Forschungstradition werden Erfahrungen von deutschschweizerischen Familien präsentiert, die HIV-infizierte und aidskranke Personen pflegen. Elf Familien (12 Frauen, 5 Männer) nahmen an Familieninterviews und neun Familienmitglieder nahmen zusätzlich an vertiefenden Gruppengesprächen teil. Eine kritische Reflexion der Ergebnisse zeigte, dass die Familien die HIV-Familienpflege in einem Kontext des Schweigens leisten. Das Schweigen wird sowohl innerhalb der Familien als auch in ihrer unmittelbaren und weiteren Umgebung praktiziert. Zwei Thesen des Schweigens werden näher beleuchtet: 1.HIV-Familien teilen ihre Erlebnisse meistens nicht mit ihrer unmittelbaren und weiteren Umgebung, weil sie mit gesellschaftlichen Stigmatisierungen, sich verändernden Familienkonstellationen und traditionellen Bildern der Familienpflege konfrontiert sind und sich in schweigende Familienzirkel zurückziehen. 2.Diskurse über Familienpflege von Erwachsenen fehlen weitgehend im deutschschweizerischen Gesundheitswesen, weil die Gesundheit der Einzelperson und nicht der Familie fokussiert wird und weil Pflegende und andere Mitarbeiter des Gesundheitswesens nicht in Familienbezügen denken. Die Resultate weisen darauf hin, dass die HIV-Familien professionelle Familienpflege dringend benötigen und dass die Pflege diesen neuen Aufgabenbereich übernehmen soll.

[Visions for the future--nursing as a profession in German-speaking Swiss health care]

Social, scholarly, and technical changes and changes in health politics have a lasting influence on the nursing profession. The development of nursing science programs can be seen in this context and institutions, which offer educational programs for nurses, have to orient them toward the new demands of the profession. Up to now in the German-speaking realm, published data, which describe the changes the nursing profession can expect, have not been available, nor have possible future fields of activity of nursing been examined. In order to close this gap, a group of opinion leaders and experts in nursing in German-speaking Switzerland were studied. Eighty-one people were surveyed by means of a questionnaire, and ten people were interviewed in-depth. The results reflect the visions and perspectives of the nursing profession of the future in German-speaking Switzerland. The expectation is that nursing should deal increasingly with sociopolitical changes and that the main issues of nursing with regard to type of client and locations where care is given will change. A re-orientation toward strengthening professional identity is called for in the following areas: involvement in determining and shaping decisions in politics and health politics; taking entrepreneurial initiatives; building clinical practice on caring, patient preferences, and evidence; making professional training and continuing education clinically-oriented as well as the development and the establishment of nursing science. Through a re-orientation, nursing should be better able to meet the challenges, which it faces because of health and social problems in the population. A great discrepancy exists between the expectations for nursing in the future and present reality. The challenge will be to see whether it will be possible to close the gap between visions and reality by means of training, continuing education, and changes in clinical practice.

[Families living with HIV and Aids--review of the literature]

This article presents the current state of the art regarding the concept of families living with HIV and Aids. The literature reflects a comprehensive view including families of origin, families of choice and partnerships. It is evident that family networks of homosexual men are most systematically described in the literature; to a lesser extent families with hemophilia and i.v. drug users and even fewer studies are found regarding families with a heterosexual transmission background and especially female family caregivers. This paper also focuses on the wide range of support offered by these family systems. The acute and mostly terminal infectious disease Aids, as observed in the 80 Dies, has now become a predominantly chronic-progressive illness. Since the mid 90 Dies, the new antiretroviral therapies have further decreased morbidity and mortality, leading to less personal care, high-tech nursing requirements and household support. This development places families in a position of providing more emotional and advocatory support and companionship over a considerably longer time span. The discussion identifies strengths and weaknesses of the current literature in order to define deficits in the Anglo-American as well as in the German speaking area. From a nursing science point of view, the characteristics of HIV/Aids care must be further acknowledged, described and systematically studied, and results must be made accessible. This is important because the knowledge acquired by studying families affected by HIV and Aids is of interest for other family systems dealing with chronically ill family members. Finally, research recommendations are listed regarding family-oriented care and future study designs.

[Becoming partners: the meaning of caring for patients with HIV and AIDS]

The purpose of this study was to understand and describe what constitutes caring as experienced by persons living with HIV and AIDS (PLWAs) along their illness trajectory. Interpretative phenomenology was employed. Six men and one woman living with HIV or AIDS participated in open-ended interviews. Interviews were analyzed according to Benner (1994) through paradigm cases, thematic analyses, and analyses of examples. Convenience sampling was used to select participants. Two distinct categories were interpreted: Letting go step by step and becoming partners. Letting go step by step encompasses the entire time people are living with HIV/AIDS illness trajectory. Becoming partners describes the relationship and commitments between PLWAs and families, friends, and health care providers. These findings reinforce the need for families, friends, and health care providers to become partners with PLWASs and to work on this partnership along the entire illness trajectory.

Support groups for people living with HIV/AIDS: a review of literature

For more than a decade, support groups have been proposed as a key intervention for people living with HIV and AIDS (PLWAs). Despite this fact, there are still only a few articles that evaluate and compare outcomes of support groups so as to provide a scientific base for their usefulness and effectiveness. The purpose of this article is to critically review selected published literature on support groups and to assess gaps in research. In general, the reviewed literature evaluated support groups as an effective intervention, which is evident for this widespread support. However, because diverse populations of PLWAs have specific needs, the group and intervention should be designed to meet those needs. Specific recommendations for further research about support groups for PLWAs are offered.

[Bibliographies on Dorothea Orem's nursing theory]

Bibliography on the subject of Dorothea Orem's nursing theory Dorothea Orem's theory is now well known in Switzerland. In many first level and continuing education courses it is taught, dealt with and critically examined. Various attempts are made to translate it into practice. This compilation shows, in the form of abstracts of various articles, how Orem's self-care-deficit theory is applied, discussed and reflected upon. Part of this paper compares Orem's theory with other nursing theories. This bibliography, like that already published in Pflege, Vol. 7, 1994, Nr. 3, was compiled in the context of the topic "Pain", as part of the Higher Professional Education Course, level 2, of the Advanced School of Nursing, Aarau.

[Admission to a ward for terminal care as a status passage]

In the last few years clinics exclusively for patients suffering from AIDS have been developed in Switzerland, specialising in terminal care. The institution in which the research here reported was carried out, admitted drug-dependent patients with AIDS. Admission to the unit, henceforth referred to as unit for the dying, is a very special event, which triggers off a variety of behavioural manifestations. The research shows that it is a case of 'status passage' as described by Glaser and Strauss (1971), which is experienced differently by each individual. In spite of individual differences, similar conditions, similar factors, which influence patients, similar coping mechanisms were observed. To end the paper, concrete suggestions are offered for the care of drug dependent patients suffering from AIDS, suggestions at the level of individual nurses, of the nursing profession and of the structure of the organisation.

[Bibliography on the topic of pain]

Many books and articles deal with sociological, psychological and other aspects of the subject of pain. They document a variety of approaches in dealing with people who suffer pain. This compilation is a synopsis of articles, almost exclusively related to nursing and nursing research. The articles illuminate a broad spectrum, covering the history of pain research, assessment of pain and the key issues in caring for and nursing patients in pain. The bibliography was produced as part of the course work of the Advanced Nursing Education Programme in Aarau. The purpose was to understand and learn about the largely English language literature on the subject and to prepare an education programme on the concept of pain. This bibliography only partially covers existing publications and consequently is not necessarily representative.

[Experiences with secondary implantation of anterior chamber lenses]

Between 1984-1990 80 secondary implantations of an anterior chamber lens in aphakic eyes have been completed. The average follow-up period was 3.1 years, some of the patients checked on during the last 6 years. The most relevant complications to mention being retinal detachment (2), as well as cystoid macular edema (1). These complications appeared in patients in whom a vitrectomy had to be performed simultaneously. Other complications like corneal dystrophy, glaucoma or lens dislocations were not observed. The risk is increased when there is the need to perform a vitrectomy simultaneously. In cases without vitrectomy the risk is slight.