bluuebunny/crossref_metadata_2025 huggingface dataset:
Role of the Toll/interleukin‐1 receptor signaling pathway in host resistance and pathogenesis during infection with protozoan parasites
Authors: Gazzinelli Ricardo T. , Ropert Catherine , Campos Marco A.
Published: September 2004

Summary:  Different studies have illustrated the activation of the innate immune system during infection with protozoan parasites. Experiments performed in vivo also support the notion that innate immunity has a crucial role in resistance as well as pathogenesis observed during protozoan infections such as malaria, leishmaniasis, toxoplasmosis, and trypanosomiasis. While major advances have been made in the assignment of bacterial molecules as Toll‐like receptors (TLRs) agonists as well as defining the role of the Toll/interleukin‐1 receptor (TIR) signaling pathway in host resistance to bacterial infection, this research area is now emerging in the field of protozoan parasites. In this review, we discuss the recent studies describing parasite molecules as TLR agonists and those studies indicating the essential role of the TIR‐domain bearing molecule named myeloid differentiation factor 88 in host resistance to infection with protozoan parasites. Together, these studies support the hypothesis that the TIR signaling pathway is involved in the initial recognition of protozoan parasites by the immune system of the vertebrate host, early resistance to infection, development of acquired immunity, as well as pathology observed during acute infection with this class of pathogens.
Effector and memory CD8+ T cells as seen in immunity to malaria
Authors: Morrot Alexandre , Zavala Fidel
Published: September 2004

Summary:  Transgenic (Tg) mice carrying a T‐cell receptor (TCR) specific for a CD8+ T‐cell epitope expressed in pre‐erythrocytic stages of Plasmodium yoelii has proven to be a valuable tool to advance our understanding of this anti‐parasite T‐cell response, as it occurs in vivo. The visualization of CD8+ T cells in vivo and ex vivo greatly facilitated research aimed at characterizing basic features of this T‐cell response such as the kinetics of differentiation and proliferation and the in vivo antigen presentation. Importantly, this research unveiled the existence of early self‐regulatory mechanisms controlling the magnitude of the CD8+ T‐cell response and also identified CD4+ T cells as critical elements in the development of memory populations. This review discusses our recent research using Tg mice and highlights our progress in understanding the CD8+ T‐cell‐mediated immunity against malaria liver stages.
Immunopathogenesis of schistosomiasis
Authors: Wynn Thomas A. , Thompson Robert W. , Cheever Allen W. , Mentink‐Kane Margaret M.
Published: September 2004

Summary:  In schistosomiasis mansoni, the chronic egg‐induced granulomatous response in the liver and intestines may eventually cause extensive tissue scarring and development of portal hypertension. Indeed, much of the morbidity and mortality associated with this disease is directly attributable to the deposition of connective tissue elements in affected tissues. Elucidating the mechanisms that regulate the severity of schistosomiasis has been a major research objective over the past several years. Research conducted with DNA microarrays as well as investigations with a variety of gene knock‐out mice have been particularly helpful in achieving this goal. A notable accomplishment in the past few years was the identification of interleukin‐13 (IL‐13) and the IL‐13 receptor complex as central regulators of disease progression in schistosomiasis. Liver fibrogenesis is severely decreased in infected IL‐13‐deficient mice as well as in wildtype animals treated with IL‐13 antagonists. In contrast, IL‐13 effector function increases dramatically in IL‐13 receptor α2 (IL‐13Rα2)‐deficient mice. These mice develop severe hepatic fibrosis, fail to downregulate granuloma formation in the chronic phase of S. mansoni infection, and succumb to the disease at an accelerated rate; thus, identifying the ‘decoy’ IL‐13 receptor as a critical life sustaining ‘off’ switch for tissue damaging egg‐induced inflammation.
The immunological challenge to developing a vaccine to the blood stages of malaria parasites
Authors: Good Michael F. , Stanisic Danielle , Xu Huji , Elliott Salenna , Wykes Michelle
Published: September 2004

Summary:  Twenty‐one years after malaria antigens were first cloned, a vaccine still appears to be a long way off. There have been periods of great excitement, and in model systems, subunit vaccine homologs can induce robust protection. However, significant challenges exist concerning antigenic variation and polymorphism, immunological non‐responsiveness to individual vaccine antigens, parasite‐induced apoptosis of immune effector and memory cells, and immune deviation as a result of maternal immunity and alterations of dendritic cell function. Novel approaches will be required. This review addresses some of the approaches that might present malaria antigens in a way designed to induce superior immune responses or that target novel conserved epitopes. Cell‐mediated immunity, acting independently of antibody, may exert potent anti‐parasite effects, and identification of multiple target antigens/epitopes could lead to the development of vaccines with profound efficacy.
Turning it on and off: regulation of dendritic cell function in Toxoplasma gondii infection
Authors: Aliberti Julio , Jankovic Dragana , Sher Alan
Published: September 2004

Summary:  Because of its intrinsic virulence, Toxoplasma gondii induces a potent interleukin‐12 (IL‐12)‐dependent cell‐mediated immune response that shuts down the growth of the replicative tachyzoite stage, thus promoting host survival and successful transmission through predation. At the same time, this response must be tightly controlled to prevent lethality due to cytokine‐mediated immunopathology. Evidence accumulated in recent years suggests that dendritic cells (DCs) play a major role in the initiation of IL‐12‐driven host resistance and that IL‐12 synthesis by DCs is carefully regulated to avoid overproduction. In addition, this work has revealed a critical role for DCs in determining the highly polarized T‐helper 1 (Th1)‐type response triggered by the parasite. In this review, we summarize our current understanding of how DC function is initiated by Toxoplasma and how parasite‐primed DCs drive Th1 effector choice. In addition, we discuss recent findings concerning the pathways responsible for endogenous regulation of DC IL‐12 production during T. gondii infection.
Does malaria suffer from lack of memory?
Authors: Struik Siske S. , Riley Eleanor M.
Published: September 2004

Summary:  It is widely perceived that immunity to malaria is, to an extent, defective and that one component of this defective immune response is the inability to induce or maintain long‐term memory responses. If true, this is likely to pose problems for development of an effective vaccine against malaria. In this article, we critically review and challenge this interpretation of the epidemiological and experimental evidence. While evasion and modulation of host immune responses clearly occurs and naturally acquired immunity is far from optimal, mechanisms to control blood‐stage parasites are acquired and maintained by individuals living in endemic areas, allowing parasite density to be kept below the threshold for induction of acute disease. Furthermore, protective immunity to severe pathology is achieved relatively rapidly and is maintained in the absence of boosting by re‐infection. Nevertheless, there are significant challenges to overcome. The need for multiple infections to acquire immunity means that young children remain at risk of infection for far too long. Persistent or frequent exposure to antigen seems to be required to maintain anti‐parasite immunity (premunition). Lastly, pre‐erythrocytic and sexual stages of the life cycle are poorly immunogenic, and there is little evidence of effective pre‐erythrocytic or transmission‐blocking immunity at the population level. While these problems might theoretically be due to defective immunological memory, we suggest alternative explanations. Moreover, we question the extent to which these problems are malaria‐specific rather than generic (i.e. result from inherent limitations of the vertebrate immune system).
Dendritic cells, pro‐inflammatory responses, and antigen presentation in a rodent malaria infection
Authors: Langhorne Jean , R. Albano Frank , Hensmann Meike , Sanni Latifu , Cadman Emma , Voisine Cecile , Sponaas Anne‐Marit
Published: September 2004

Summary:  An infection of mice with Plasmodium chabaudi is characterized by a rapid and marked inflammatory response with a rapid but regulated production of interleukin‐12 (IL‐12), tumor necrosis factor‐α (TNF‐α), and interferon‐γ (IFN‐γ). Recent studies have shown that dendritic cells (DCs) are activated in vivo in the spleen, are able to process and present malaria antigens during infection, and may provide a source of cytokines that contribute to polarization of the CD4 T‐cell response. P. chabaudi‐infected erythrocytes are phagocytosed by DCs, and peptides of malaria proteins are presented on major histocompatibility complex (MHC) class II. The complex disulfide‐bonded structure of some malaria proteins can impede their processing in DCs, which may affect the magnitude of the CD4 T‐cell response and influence T‐helper 1 (Th1) or Th2 polarization. DCs exhibit a wide range of responses to parasite‐infected erythrocytes depending on their source, their maturational state, and the Plasmodium species or strain. P. chabaudi‐infected erythrocytes stimulate an increase in the expression of costimulatory molecules and MHC class II on mouse bone marrow‐derived DCs, and they are able to induce the production of pro‐inflammatory cytokines such as IL‐12, TNF‐α, and IL‐6, thus enhancing the Th1 response of naïve T cells. IFN‐γ and TNF‐α play a role in both protective immunity and the pathology of the infection, and the inflammatory disease may be regulated by IL‐10 and transforming growth factor‐β. It will therefore be important to elucidate the host and parasite molecules that are involved in activation or suppression of the DCs and to understand the interplay between these opposing forces on the host response in vivo during a malaria infection.
Generation, specificity, and function of CD8+ T cells in Trypanosoma cruzi infection
Authors: Martin Diana , Tarleton Rick
Published: September 2004

Summary:  CD8+ T cells are crucial to the control of Trypanosoma cruzi infection and probably act via multiple mechanisms, the most important being the production of interferon‐γ (IFN‐γ). In the absence of CD8+ T cells, mice quickly succumb to the infection or develop a more severe chronic disease. Reduced production of IFN‐γ by CD8+ T cells is also associated with increased severity of chagasic disease in humans. CD8+ T cells in chronic T. cruzi infection are maintained as effector memory cells, undergo rapid expansion, and demonstrate effector functions following re‐exposure to antigen. However, the initial generation of T. cruzi‐specific CD8+ T‐cell responses appears to be relatively slow to develop. In addition, the expression of the effector function of the CD8+ T cells is compromised in some tissues, particularly in muscle. The targets of effective CD8+ T‐cell responses in T. cruzi infection are multiple and varied, and they represent some of the best vaccine candidates described to date. Further analysis of CD8+ T cells will provide insight into the disease process in T. cruzi infection and should identify methods to assess and enhance immunity to T. cruzi infection and protection from the symptoms of Chagas' disease.
Requirements for the development of IL‐4‐producing T cells during intestinal nematode infections: what it takes to make a Th2 cell in vivo
Authors: Liu Zhugong , Liu Qian , Pesce John , Anthony Robert M. , Lamb Erika , Whitmire Jeannette , Hamed Hossein , Morimoto Motoko , Urban Joseph F. , Gause William C.
Published: September 2004

Summary:  Components of the type 2 immune response may mediate host protection against both helminthic parasites and harmful allergic responses. A central player in this response is the T‐helper 2 (Th2) effector cell, which produces interleukin (IL)‐4, IL‐5, IL‐13, and other Th2 cytokines during the primary and memory response. Specific aspects of the parasite that trigger Th2‐cell differentiation are not yet defined. Furthermore, the cell types and cell surface and secreted molecules that provide the immune milieu required for the development of Th2 effector cells and also Th2 memory cells are not well understood. They will probably vary with the particular helminth or other antigen inducing the Th2 response. We have used third stage larvae of intestinal nematode parasites as adjuvants to promote naïve nonparasite antigen‐specific T cells to differentiate into Th2 cells. This model system avoids possible parasite antigen‐specific T‐cell clones or cross‐reactive memory T cells that may preferentially differentiate into Th2 effector cells during the course of infection and confound the stereotypical components of parasite‐induced Th2 cell differentiation. We have found that these parasites have a potent adjuvant effect and have used our model system to begin to investigate the events that lead to the development of polarized Th2 cells in vivo.
The immunopathology of experimental visceral leishmaniasis
Authors: Kaye Paul M. , Svensson Mattias , Ato Manabu , Maroof Asher , Polley Rosalind , Stager Simona , Zubairi Soombul , Engwerda Christian R.
Published: September 2004

Summary:  Experimental murine infection with the parasites that cause human visceral leishmaniasis (VL) results in the establishment of infection in the liver, spleen, and bone marrow. In most strains of mice, parasites are eventually cleared from the liver, and hepatic resistance to infection results from a coordinated host response involving a broad range of effector and regulatory pathways targeted within defined tissue structures called granulomas. In contrast, parasites persist in the spleen and bone marrow by mechanisms that are less well understood. Parasite persistence is accompanied by the failure of granuloma formation and by a variety of pathologic changes, including splenomegaly, disruption of lymphoid tissue microarchitecture, and enhanced hematopoietic activity. Here, we review the salient features of these distinct tissue responses and highlight the varied roles that cytokines of the tumor necrosis factor family play in immunity to this infection. In addition, we also discuss recent studies aimed at understanding how splenomegaly affects the survival and function of memory cells specific for heterologous antigens, an issue of considerable importance for our understanding of the disease‐associated increase in secondary infections characteristic of human VL.
New lessons from old pathogens: what parasitic infections have taught us about the role of nuclear factor‐κB in the regulation of immunity
Authors: Mason Nicola J. , Artis David , Hunter Christopher A.
Published: September 2004

Summary:  The nuclear factor‐κB (NF‐κB) family of transcription factors is activated by many infectious and inflammatory stimuli. This family regulates the expression of multiple genes, whose products include cytokines, chemokines, adhesion molecules, and antiapoptotic factors that are important components of the innate and adaptive immune response. A prominent role of NF‐κB transcription factors in resistance to a variety of infectious diseases was revealed by studies with mice that lack individual family members. However, little is known about the basis for these effects or about the role of individual family members during a coordinated immune response to infection. Diverse parasites such as Toxoplasma gondii, Leishmania major, and Trichuris muris provide a unique opportunity to understand the role of the NF‐κB system in the development of innate and adaptive immunity to these infections. The basis for resistance and susceptibility to these parasites is well understood, and studies using these experimental systems have provided unique insights into the role of NF‐κB in the regulation of T‐helper 1 cell (Th1) and Th2 type responses. It has become clear that NF‐κB family members have cell lineage‐specific functions and that their relative importance varies with type of infection as well as route of pathogen entry. Thus, studies with models of parasitic infection have revealed that individual NF‐κB family members perform distinct, nonoverlapping, and biologically significant functions in the regulation of immunity and inflammation.
Does the Leishmania major paradigm of pathogenesis and protection hold for New World cutaneous leishmaniases or the visceral disease?
Authors: McMahon‐Pratt Diane , Alexander James
Published: September 2004

Summary:  Parasitic protozoa of the genus Leishmania have provided a useful perspective for immunologists in terms of host defense mechanisms critical for the resolution of infection caused by intracellular pathogens. These organisms, which normally reside in a late endosomal, major histocompatibility complex (MHC) class II+ compartment within host macrophages cells, require CD4+ T‐cell responses for the control of disease. The paradigm for the CD4+ T‐helper 1 (Th1)/Th2 dichotomy is largely based on the curing/non‐curing responses, respectively, to Leishmania major infection. However, this genus of parasitic protozoa is evolutionarily diverse, with the cutaneous disease‐causing organisms of the Old World (L. major) and New World (Leishmania mexicana/ Leishmania amazonensis) having diverged 40–80 million years ago. Further adaptations to survive within the visceral organs (for Leishmania donovani, Leishmania chagasi, and Leishmania infantum) must have been required. Consequently, significant differences in host–parasite interactions have evolved. Different virulence factors have been identified for distinct Leishmania species, and there are profound differences in the immune mechanisms that mediate susceptibility/resistance to infection and in the pathology associated with disease. These variations not only point to interesting features of the host–pathogen interaction and immunobiology of this genus of parasitic protozoa, but also have important implications for immunotherapy and vaccine development.
Helminth parasites – masters of regulation
Authors: Maizels Rick M. , Balic Adam , Gomez‐Escobar Natalia , Nair Meera , Taylor Matt D. , Allen Judith E.
Published: September 2004

Summary:  Immune regulation by parasites is a global concept that includes suppression, diversion, and conversion of the host immune response to the benefit of the pathogen. While many microparasites escape immune attack by antigenic variation or sequestration in specialized niches, helminths appear to thrive in exposed extracellular locations, such as the lymphatics, bloodstream, or gastrointestinal tract. We review here the multiple layers of immunoregulation that have now been discovered in helminth infection and discuss both the cellular and the molecular interactions involved. Key events among the host cell population are dominance of the T‐helper 2 cell (Th2) phenotype and the selective loss of effector activity, against a background of regulatory T cells, alternatively activated macrophages, and Th2‐inducing dendritic cells. Increasingly, there is evidence of important effects on other innate cell types, particularly mast cells and eosinophils. The sum effect of these changes to host reactivity is to create an anti‐inflammatory environment, which is most favorable to parasite survival. We hypothesize therefore that parasites have evolved specific molecular strategies to induce this conducive landscape, and we review the foremost candidate immunomodulators released by helminths, including cytokine homologs, protease inhibitors, and an intriguing set of novel products implicated in immune suppression.
Immune‐mediated regulation of chronic intestinal nematode infection
Authors: Hayes Kelly S. , Bancroft Allison J. , Grencis Richard K.
Published: September 2004

Summary:  Gastrointestinal nematode infection is extremely prevalent worldwide in humans and animals. Infection levels vary between individuals in infected populations and exhibit a negative binomial distribution, and some individuals appear to be predisposed to certain infection levels. Moreover, infection tends to be chronic, despite evidence for the acquisition of some degree of acquired immunity. The host is subject to constant and repeated antigenic challenge, and individuals vary in the response they make. While a considerable amount of information is emerging on the immunoregulatory mechanisms operating during acute nematode infection from a variety of laboratory model systems, relatively little work has been carried out on the immune mechanisms underlying chronic infection. This review details some of the work that has addressed this important facet of gut nematode infection, highlighting studies from model systems that give insight into the induction of nonprotective immunity, while at the same time avoiding the induction of host‐damaging pathology.
Interleukin‐13 in the skin and interferon‐γ in the liver are key players in immune protection in human schistosomiasis
Authors: Dessein Alain , Kouriba Bourema , Eboumbou Carole , Dessein Helia , Argiro Laurent , Marquet Sandrine , Elwali Nasr‐Eldin M. A. , Rodrigues Virmondes , Li Yuesheng , Doumbo Ogobara , Chevillard Christophe
Published: September 2004

Summary:  Immunity against schistosomes includes anti‐infection immunity, which is mainly active against invading larvae in the skin, and anti‐disease immunity, which controls abnormal fibrosis in tissues invaded by schistosome eggs. Anti‐infection immunity is T‐helper 2 (Th2) cell‐dependent and is controlled by a major genetic locus that is located near the Th2 cytokine locus on chromosome 5q31‐q33. Mutations in the gene encoding interleukin (IL)‐13 that decrease or increase IL‐13 production account, at least in part, for that genetic control. In contrast, protection against hepatic fibrosis is dependent on interferon (IFN)‐γ and is controlled by a major genetic locus that is located on 6q23, near the gene encoding the IFN‐γ receptor β chain. Mutations that modulate IFN‐γ gene transcription are associated with different susceptibility to disease. These data indicate that IL‐13 in the skin and IFN‐γ in the liver are key players in protective immunity against schistosomes. These roles relate to the high anti‐fibrogenic activities of IFN‐γ and to the unique ability of IL‐13 in Th2 priming in the skin and in the mobilization of eosinophils in tissues. The coexistence of strong IFN‐γ and IL‐13‐mediated immune responses in the same subject may involve the compartmentalization of the anti‐schistosome immune response between the skin and the liver.
Toward an understanding of the interaction between filarial parasites and host antigen‐presenting cells
Authors: Semnani Roshanak Tolouei , Nutman Thomas B.
Published: September 2004

Summary:  Lymphatic filarial infection, from an immunologic point of view, is one of the most complex parasite infections. Not only are there different clinical manifestations that reflect differing immune responses, but the parasite's multiple stages, each with distinct anatomic tropism, add a compartmental layer of complexity to an already complicated process. Moreover, these parasites have finely tuned immune evasion strategies that enable escape from the innate immune system. As different stages of the parasite interact with different types of antigen‐presenting cells that, in turn, may play a significant role in shaping the subsequent adaptive immune response, the focus of this review is to provide insight into the interaction between filarial parasites and antigen‐presenting cells with an eye toward understanding how they influence parasite antigen‐driven T‐cell responses.
The immunobiology of Th1 polarization in high‐pathology schistosomiasis
Authors: Stadecker Miguel J. , Asahi Hiroko , Finger Eduardo , Hernandez Hector J. , Rutitzky Laura I. , Sun Jing
Published: September 2004

Summary:  Schistosomiasis is a serious global helminthic disease, in which the main immunopathology consists of a granulomatous and fibrosing reaction against tissue‐trapped parasite eggs. The severity of this inflammatory process, the product of a CD4+ T‐cell‐mediated immune response against parasite egg antigens, is, however, markedly uneven, both in human patients and among mouse strains in an experimental model. Severe schistosomiasis is associated with persistently elevated pro‐inflammatory T‐helper‐1 (Th1)‐type cytokines, whereas milder pathology is present when Th2 cytokines dominate. This scenario is supported by the pronounced pathology resulting from the obliteration of pathways that facilitate Th2 differentiation and by the development of more intense lesions in mouse strains that fail to downregulate the Th1 response. Genetically prone high‐pathology mice have a higher proportion of CD4+ T cells in lymph nodes and granulomas, in which the Th1 phenotype is driven by interleukin‐12; they also develop a dominant repertoire against peptide 234–246 of the major Sm‐p40 egg antigen, utilizing a strikingly restricted T‐cell receptor structure that involves Vα11.3β8. In turn, low‐pathology mice exhibit enhanced CD4+ T‐cell apoptosis, which contributes to limit pathology. The definition of distinctive immune profiles associated with polar forms of schistosomiasis opens opportunities for targeted immuno‐intervention in individuals suffering from or at risk of severe disease.
The development of effector and memory T cells in cutaneous leishmaniasis: the implications for vaccine development
Authors: Scott Phillip , Artis David , Uzonna Jude , Zaph Colby
Published: September 2004

Summary:  Leishmania major infections induce the development of a CD4+ T‐helper 1 (Th1) response that not only controls the primary infection but also results in life‐long immunity to reinfection. How that immunity is maintained is unknown, although because of the existence of infection‐induced immunity, there has been an assumption that the development of a vaccine against leishmaniasis would be relatively easy. This has turned out not to be the case. One problem has been the finding that a large part of the immunity induced by a primary infection depends upon the presence of persistent parasites. Nevertheless, there are ample situations where immunologic memory persists without the continued presence of antigen, providing the prospect that a non‐live vaccine for leishmaniasis can be developed. To do so will require an understanding of the events involved in the development of an effective protective T‐cell response and, more importantly, an understanding of how to maintain that response. Here, we review work from our laboratory, describing how Th1 cells develop in L. major‐infected mice, the nature of the memory T cells that provide protection to reinfection, and how that information may be utilized in the development of vaccines.
Does unemployment hysteresis falsify the natural rate hypothesis? a meta‐regression analysis
Authors: Stanley T. D.
Published: September 2004

Abstract.  A quantitative survey of 24 studies containing 99 national estimates of unemployment persistence reinstates unemployment hysteresis as a viable falsifying hypothesis to the natural rate hypothesis. Empirical evidence to the contrary may be attributed to small‐sample, misspecification and publication biases. Larger estimates of unemployment persistence are produced by models that use more information (t = 9.03; P < 0.0001) and are better specified. A theme of bias and misspecification among studies that are more supportive of natural rate hypothesis emerges in several independent ways. The nonstationarity of the unemployment rate is confirmed both by the observed rate of convergence of persistence estimates across the empirical literature and by the point towards which they converge. The natural rate hypothesis may be regarded as ‘falsified’ should we choose to do so.
Stroke care in the home: the impact of social support on the general health of family caregivers
Authors: Sit Janet WH , Wong Thomas KS , Clinton Michael , Li Leonard SW , Fong Yee‐man
Published: September 2004

Background.  Throughout the stroke rehabilitation process, community care is one of the most important elements. Learning to live with and take care of a family member with a stroke is immensely complex and demanding. Without appropriate support, family caregivers are at risk of their own general health decreasing, thus becoming a patient themselves – the second patient in the family.

Aim.  The aim of this study was to examine aspects of social support available to family caregivers during the first 12‐week transitional period following hospital discharge.

Design and method.  This study adopted a cross‐sectional descriptive design. Regression analysis was performed for examining the types of social support received and the general health of family caregivers. Open‐ended questions were used to gain a better understanding of situation‐specific supports including their availability, utilization and eventual satisfaction.

Results.  Findings confirm that home care for the stroke survivor is heavy and demanding. Health‐related care tasks were the most stressful. Around 40% of the family caregivers reported somatic symptoms. Fewer persons in the social network of the family caregivers had provided support compared with the number of support people that caregivers thought available. Two inadequate types of support were tangible support and information support. Professional advice and feedback in relation to home care skills were particularly lacking.

Conclusion.  Findings of this study affirmed that stroke care needs exceed the hospital boundary. Professional support to family caregivers is essential so as to sustain home care and protect the caregiver's health. This is particular important during the first 12 weeks transitional period after hospital discharge.

Relevance to clinical practice.  This study highlighted the implications of social support to nursing practice, especially in predischarge planning and community care. Findings of this study may provide information and data for service planning and community resources co‐ordination to support community stroke care.
Mental health: integrated network and family‐oriented model for co‐operation between mental health patients, adult mental health services and social services
Authors: Piippo Jukka , Aaltonen Jukka
Published: September 2004

Background.  Co‐operation between mental health care units and the social services is important in the case of people with social problems who also suffer from mental health problems. However, participation of patients and their families in the treatment process, and co‐operation between them and the professionals, are also important. Communication between the professionals, patients and their family members, and the professionals is a crucial factor for co‐operation.

Aims and objectives.  The aim of this study was to elucidate the experiences and importance of co‐operation for the patients. The data consisted of interviews with 22 mental health patients who were also clients of municipal social services.

Method.  The grounded theory approach was used, focusing on the informants’ experiences of the integrated network and family‐oriented model for co‐operation.

Results.  The findings indicate the importance of the participation of patients and their social networks in psychiatric care or the treatment process. Meetings should be characterized by open and reflexive discussions with all participants’ points of view being included, so that fruitful co‐operation is possible. However, some negative experiences were also reported, all of which were connected with the professionals’ behaviour.

Conclusions.  Trust and honesty are essential elements in relations between professionals and psychiatric patients, but it cannot be assumed that they will develop naturally. It is the professionals’ responsibility to adjust their behaviour so that these elements can be created in a mutual process between patients and professionals. Multidisciplinary teams are a necessity in family‐oriented co‐operation between psychiatry and social services, and in a satisfactory caring process.

Relevance to clinical practice.  Nurses’ work is often individually oriented and nurses are ruled by routines in their work. The mental health caring process should be seen as a shared process between the patient, his/her human environment and professionals for which nurses need skills to their interaction with patients and their social network.
A framework for understanding clinical reasoning in community nursing
Authors: Carr Susan M
Published: September 2004

Background.  Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge‐guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision‐making processes.

Aims.  Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context.

Design.  An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture.

Methods.  Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data.

Results.  All nurses may engage with the same concepts – health, need, care and partnerships – but organized into particular frames by the guiding practice philosophy and service organization. A four‐stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi‐faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision‐making process.

Conclusions.  Environment of care has significant implications on need identification and response.

Relevance to clinical practice.  Mechanisms to enhance the sharing of clinical reasoning and decision‐making transparency are essential to aid inter‐ and intra‐professional communication. Presentation of a clinical reasoning framework exposes the breath of ‘signals’ encountered in practice and the range of knowledge employed in understanding and responding to patient need.
District nursing – sharing an understanding by being present. Experiences of encounters with people with serious chronic illness and their close relatives in their homes
Authors: Öhman Marja , Söderberg Siv
Published: September 2004

Background. In the homecare setting, district nurses assume a heavy responsibility and are involved in a variety of care activities. They view themselves as having a central role in care at home that centres on the development of a relationship with those who are ill and their families.

Aim. The aim of this study was to elucidate the meaning of district nurses experiences of encounters with people with serious chronic illness and their close relatives in their homes. A purposive sample of 10 district nurses (female) was interviewed using a narrative approach.

Method. To achieve the aim, a phenomenological hermeneutic interpretation inspired by the philosophy of Ricoeur was used to interpret the interview text.

Results. This study proposes that district nurses’ experiences of encounters with people with serious chronic illness and their close relatives in their homes can be understood as district nurses being welcomed into the ill people's privacy, to share their intimacy and their understanding of being ill. This close relationship enables them to alleviate and to console the suffering and loneliness caused by illness. This is expressed in the three themes: being in a close relationship, sharing an understanding and weaving a web of protection.

Conclusion. It seems that by being entirely present, in a close relationship, district nurses share the experiences of illness and through interpretation of the whole persons’ expressions; they share an understanding of this illness experience. In this close relationship, at the home of the ill people and their close relatives, district nurses are available to alleviate people's suffering and loneliness caused by illness.

Relevance to clinical practice. This study reveals the need to be entirely present in encounters between the district nurses and people with serious chronic illness and their close relatives. This relation makes it possible to establish a shared understanding of the illness experience. Being aware of the importance of this shared understanding within a relationship, will increase the health care personnel's possibility to alleviate and console those suffering of illness. This proposed interpretation could be useful for reflection of care interventions, in education and supervision of district nurses.
Nurse prescribers’ experiences of prescribing
Authors: Lewis‐Evans Amanda , Jester Rebecca
Published: September 2004

Background.  Nurse prescribing has advanced rapidly over the previous decade and is clearly on the agenda for the future. Previous research considers nurse prescribing from the patient's perspective, the medical professions’ stance and the legal and ethical implications. However, there is a paucity of literature that explores the experiences of nurse prescribers’ within their current role. These experiences need investigating to ensure nurse prescribing is able to advance in ways that provide benefit to nurses and thus provides the impetus for the study.

Aim.  To explore and review nurse prescribers’ experiences of prescribing.

Design methods.  A purposeful sample of seven nurse prescribers currently prescribing within a West Midlands Community Trust underwent minimally structured interviews in this qualitative study. Transcribed interviews were analyzed using thematic analysis.

Findings.  Four themes were generated from analysis of the interviews, ‘patient centred care’, ‘benefits of nurse prescribing’, ‘support and role satisfaction’ and finally ‘prescribing difficulties’.

Conclusions.  Nurse prescribers’ perceive prescribing as a predominantly positive experience, frequently asserting the advantages that prescribing saves the patient and nurse time, is more convenient for the patient and increases the nurses’ autonomy and role satisfaction. However, negative experiences of restrictions to practice as a result of nurse prescribers’ formulary limitations and duplication of documentation were also described.

Relevance to clinical practice.  Nurse prescribing is a rapidly evolving area of practice with the potential to advance nursing roles. This research aims to provide an insight into the experiences of current nurse prescribers that may then be disseminated and applied to future practice.
Lecturer practitioners in UK nursing and midwifery: what is the evidence? A systematic review of the research literature
Authors: Williamson Graham R
Published: September 2004

Background.  Lecturer practitioner roles have been widely established in the UK, and are seen as having the ability to overcome the theory–practice gap in nursing, as well as offering other benefits including functioning as a link between education and practice.

Aims and objectives.  This article systematically reviews the research literature on UK lecturer practitioner roles in nursing and midwifery, in order to construct a picture of the themes that emerge from their national implementation.

Conclusions.  Only eight published research studies meeting the inclusion criteria were identified in journals, and five more included from the ‘grey literature’, totalling 13 suitable research reports. Of these 13 papers, six involved nurses and midwives. Key themes from the literature are outlined and discussed. There is an overwhelming preference for qualitative methodologies, although there is a strong argument for quantitative work in mixed‐methods studies.

Relevance to clinical practice. Lecturer practitioner roles can make an important contribution to nursing and midwifery education, but this is problematic. It is essential that managers clarify the purpose, responsibilities, support and review of lecturer practitioner roles if they are to be successful.
Management of fluid and hydration in patients with acute subarachnoid haemorrhage – an action research project
Authors: Cook Neal F , Deeny Pat , Thompson Kate
Published: September 2004

Background.  The contemporary role of the nurse in managing fluid and hydration in patients is currently ill‐defined. Considering the pivotal function nurses have in the delivery of fluid therapies, and the high priority such therapies have in the successful treatment and prevention of secondary brain injury in subarachnoid haemorrhage, the clarification of this role is essential.

Aims and objectives.  This research aims to clarify the nurse's role in fluid therapies in relation to subarachnoid haemorrhage. The objectives were to determine how nurses presently see their role in relation to fluid management in patients with subarachnoid haemorrhage, to determine the cues to guide their practice, and how this role corresponds to current patient care. A final objective was to identify how the nurse's role can be maximized to provide optimal patient care.

Methodological design.  This project takes an action research approach to examining the nurse's role in the care of patients with subarachnoid haemorrhage. A combination of focus groups, physiological data, nursing and medical documentation and a review of recent literature were used to meet the aims and objectives of the project.

Results.  The results illustrate that, while nurses involved in the study are knowledgeable about fluid and hydration in subarachnoid haemorrhage, they have an ambiguity surrounding their role. Improvements can be made in the quality of patient care through educational sessions for staff and clarification of medical and nursing interdisciplinary roles.

Conclusion.  This action research project has gone a considerable distance towards begin clarifying this role, and has illustrated clearly that the nurse's role is pivotal to the successful implementation of such treatments. With further education and collaboration with the interdisciplinary team the nurses’ role can be expanded to provide optimal, and dynamic patient‐centred care.

Relevance to clinical practice.  The results of this study highlight gaps within contemporary nursing and medical approaches to patients with subarachnoid haemorrhage, highlighting areas for improvement. It also begins to clarify the role of the nurse, with evidence of the cues they use to guide their practice.
Concordance with community mental health appointments: service users’ reasons for discontinuation
Authors: Hostick Tony , Newell Rob
Published: September 2004

Background.  Quality issues are being given renewed emphasis through clinical governance and a drive to ensure service users’ views underpin health service development.

Aims.  To establish service users’ reasons for discontinuation of community based mental health appointments in one National Health Service Trust.

Method.  A two‐phase survey of all non‐completers over a year. Phase one using a structured postal questionnaire. Phase two using structured interviews with respondents to phase one by post, telephone and face to face.

Results.  A total of 243 discharges because of non‐completion were identified by local services over the 12 months of the study and followed up by initial questionnaire. This represents 8.19% of all discharges (2967) within the same period. Forty‐four users were engaged and followed up within phase two of the survey. Data were subject to both quantitative and qualitative analysis.

Conclusions.  Analysis of responses suggests that the main reasons for non‐completion are because of dissatisfaction although the reasons are varied and the interplay between variables is complex. Whilst this user group are not apparently suffering from ‘severe mental illness’, there is clear, expressed need for a service.

Relevance to clinical practice.  Whoever provides such a service should be responsive to expressed need and a non‐medical approach seems to be favoured. If these needs are appropriately met then users are more likely to be engaged and satisfaction is likely to be improved. Although this in itself does not necessarily mean improved clinical outcomes, users are more likely to stay in touch until an agreed discharge. Practical problems of applied health service research are discussed and recommendations are made for a review of referral systems, service delivery and organization with suggestions for further research.
Stroke and eating difficulties: long‐term experiences
Authors: Carlsson Eva , Ehrenberg Anna , Ehnfors Margareta
Published: September 2004

Background.  Previous studies have shown that eating difficulties after stroke are common and often associated with communication problems. These difficulties, however, have mainly been studied from a professional perspective. Although numerous aspects of dysfunction have been identified, little knowledge exists about the experiences of living with eating difficulties.

Aim.  To explore how people affected by stroke experience living with eating difficulties, during a prolonged period.

Design.  Explorative, qualitative case study.

Methods.  Repeated interviews and participant observations with three persons 1.5–2 years after their last stroke. Data were analysed using qualitative analysis.

Results.  Eating difficulties after stroke were experienced as Striving to live a normal life, with the subthemes Abandoned to learn on one's own, Experiences of losses and Feeling dependent. The process of getting back to a life that resembled life before the stroke was experienced as long‐lasting and hard work. The informants felt that they were abandoned to manage eating training on their own. The informants experienced a loss of functional eating ability and the ability to perform activities related to food and meals. Feelings of dependence were experienced in mealtime situations.

Conclusion.  Living with eating difficulties after stroke is a complex phenomenon. The informants felt abandoned because of lack of support from the nursing staff. They were left on their own to deal with the difficult process of adjusting to a new way of eating and losses regarding mealtime activities. The combination of repeated interviews and participant observations seemed to be an approach that should be tested in larger studies.

Relevance to clinical practice.  This case study indicates a need for nurses to develop and use evidence‐based guidelines for eating training during the continuum of care. Nurses need to assess patient's habits and desires related to eating, and to adjust environment according to patient preferences.