There are differences in early morbidity after ACL reconstruction when comparing patellar tendon and semitendinosus tendon graft. A prospective randomized study of 107 patients

The main objective of this study was to study solely early postoperative morbidity following anterior cruciate ligament (ACL) reconstruction by comparing the gold standard procedure, the bone-patellar tendon-bone graft (BTB), and one of the most common alternatives, the semitendinosus tendon graft (ST). The prospective study included 107 randomized patients (50 BTB and 57 ST). The follow-up period was set to 20-35 weeks postoperatively (mean 26.8 +/- 3.5 weeks). One patient suffered early graft rupture and 89 (84%) of the remaining 106 patients were able to attend the follow-up within the given time limit. There were no differences in sick leave between the groups. The Lysholm score, Tegner activity level score and Visual Analog Scales (VAS) with the questions "How does your knee function?" and "How does your knee affect your activity level?" revealed no differences between the groups. Subjective patellofemoral pain, patellofemoral compartment findings and donor site morbidity were more common in the BTB group, P < 0.05. Lachman test grade 1+ was more common in the ST group, P < 0.05, but there was no significant difference in instrumented Lachman side-to-side comparison. The ST group scored better in the one-leg hop test than the BTB group, P < 0.05. No correlations between these clinical and functional findings and subjective knee function scores were found. In conclusion, ACL reconstruction with ST tendon graft presented fewer short-term postoperative problems as compared to reconstruction with BTB.

Dendritic cell vaccination protects mice against lethality caused by genital herpes simplex virus type 2 infection

We have evaluated the ability of antigen pulsed bone-marrow derived dendritic cells (bmDC), to induce protective immunity against a genital tract infection with herpes simplex virus type 2 (HSV-2) in mice. Intravenous but not vaginal administrations of bmDC pulsed in vitro with UV-inactivated HSV-2, or with purified HSV-2 envelope glycoproteins gave rise to complete protection against disease, as well as death caused by genital herpes infection. Protection was dependent on the antigens being presented by the bmDC as neither the antigens alone, nor the mock-pulsed bmDC prevented disease. Immunity was associated with HSV-2 specific IFN-gamma and antibody production, and was shown to be dependent on CD4(+) cells secreting IFN-gamma. Thus, ex vivo antigen-pulsed bmDC represents a powerful tool for the study of protective immunity to genital herpes infection, and for the identification of protective antigens. These findings might also have an impact on the design of vaccines against other sexually transmitted viral diseases.

A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up.

No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05).

We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial.

A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial.

The nontoxic tripeptide glycyl-prolyl-glycine amide inhibits the replication of human immunodeficiency virus type 1

OBJECTIVE

To determine whether short peptides corresponding to the RGPGR motif of the V3 loop of gp 120 have anti-human immunodeficiency virus type 1 (anti-HIV-1) activity.

DESIGN/METHODS

Short peptides were tested against the HIV-1 laboratory strains and clinical isolates.

RESULTS

The tripeptide glycyl-prolyl-glycine amide (GPG-NH2) inhibited the replication of both laboratory strains and 47 clinical isolates, including 19 strains that were resistant to other drugs or that were from patients with failing therapy. The 50% inhibitory concentrations values were 2.7 to 37 microM. Phenotypic change of two isolates from nonsyncytia-inducing to syncytia-inducing did not change their sensitivity to GPG-NH2. The tripeptide added to the antiviral effect of both zidovudine and ritonavir.

CONCLUSIONS

The tripeptide GPG-NH2 is a nontoxic compound that inhibits the replication of HIV-1 by an apparently new mode of action. Glycyl-prolyl-glycine-NH2 might prove useful by itself or as a lead compound for the treatment of drug-resistant HIV-1. Glycyl-prolyl-glycine-NH2 is currently undergoing phase I/II human clinical trials in Sweden.

Increased plasma endothelin-1 and intraplatelet cyclic guanosine monophosphate in men with disturbed glucose metabolism

Plasma endothelin-1, the nitric oxide (NO) mediator intraplatelet cyclic guanosine monophosphate (cGMP), the prostacyclin mediator cyclic adenosine monophosphate (cAMP) and the macrophage derived inflammatory mediator plasma neopterin were measured in men with Type 2 diabetes mellitus (n=91), impaired glucose tolerance (IGT; n=51), previously abnormal glucose tolerance (PAGT; n=20), and 34 healthy control men. Plasma endothelin-1was higher in men with Type 2 diabetes mellitus than in controls [4.1 (1.0-14.3) vs. 2.1 (0.2-8. 7) ng/l; P<0.001). Intraplatelet cGMP was higher in men with PAGT [0. 84 (0.57-2.76) pmol/10(9) platelets; P<0.05], IGT [0.85 (0.48-3.53); P<0.001] and Type 2 diabetes mellitus [0.90 (0.47-3.86); P<0.001] than in controls [0.70 (0.42-1.70]. No differences existed between groups concerning intraplatelet cAMP or plasma neopterin. Plasma endothelin-1 correlated with fasting plasma glucose (r=0.33; P<0.001) and HbA1(c) (r=0.29; P<0.001). In conclusion, elevated plasma endothelin-1 in Type 2 diabetes mellitus and its relationship to glucose and HbA1(c) suggest a putative role for endothelin-1 in diabetic endothelial cell damage. Increased cGMP indicating enhanced production/activity of NO suggests that factors other than reduced NO activity contribute to enhanced platelet aggregation in diabetes.

Induction and expression of intestinal humoral immunity in HIV-infected individuals: prospects for vaccination against secondary enteric infections

In view of the high incidence and severity of AIDS-related mucosal complications and secondary mucosal infections, we have evaluated the impact of HIV infection on the mucosal humoral immune status. By measuring the number of total and specific antibody-secreting cells in duodenal biopsies, we could show that HIV infection induces a pronounced polyclonal B-cell activation already in the early stages of the disease. Furthermore, we could document normal mucosal B-cell responses following oral vaccination, also in the late stages of the disease, and despite a lack of concomitant systemic responses. The relevance of these observations will be discussed with respect to the possibility of vaccinating HIV-infected individuals against secondary opportunistic infections.

Differential effect of cholera toxin on CD45RA+ and CD45RO+ T cells: specific inhibition of cytokine production but not proliferation of human naive T cells

We have studied how cholera toxin (CT) and its non-toxic cell-binding B-subunit (CTB) affect the activation of pure human T cells in an anti-CD3-driven system. CT, as opposed to CTB, strongly suppressed the proliferative responses as well as cytokine production in CD4+ and CD8+ T cells. CT however, had a differential effect on naive and activated/memory T cell subsets. Costimulation through exogenous IL-2 or through CD28 cross-linking rescued the proliferation of CT-treated naive CD45RA+ T cells, but not of activated/memory CD45RO+ cells. IL-2 production and IL-2 receptor expression were markedly reduced by CT in all T cell fractions, i.e. also in CD45RA+ cells which had maintained proliferative responses. However, the proliferative responses of CT-treated CD45RA+ T cells were IL-2-dependent, as shown by blocking experiments using anti-IL-2 antibodies. These results indicate (i) that CTB has no cytostatic effect on human T cells, (ii) that CT affects proliferation and cytokine production by two different signal pathways, and (iii) that CT might interact with a signal pathway generated through or influenced by CD45.

Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study

BACKGROUND

Bacterial vaginosis (BV) and intermediate flora is known risk-factor for postoperative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy.

AIM

To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion.

DESIGN

Prospective, double-blinded, placebo-controlled, multicenter study.

MATERIAL AND METHODS

Consecutive women attending for surgical termination prior to 11+4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables.

RESULTS

Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal flora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group.

CONCLUSION

Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora).

The patient's perceived caring needs: measuring the unmeasurable

The aim of this study is to elucidate the phenomenon of the caring need in the life-world of the patient and, on the basis of this, to compare patients' perceived caring needs with the six areas of need contained in a new instrument for patient classification, the Oulu Patient Classification (OPC). A total of 75 patients were interviewed and the data were analysed by means of a phenomenological-hermeneutical method. Seventeen perceived caring needs emerged from the process of interpretation. The patients experienced themselves as an indivisible unit that contained existential/spiritual needs and desires. The patients' caring needs are constituted from their problems, needs and desires, where human desire for life, love and meaningfulness may, express itself as bodily, psychical and existential/spiritual needs. A comparison between the patients' perceived caring needs and the OPC shows that patients' existential/spiritual needs do not emerge clearly enough and that the instrument should be supplemented by a caring perspective.

Anatomic segmentation of the intestinal immune response in nonhuman primates: differential distribution of B cells after oral and rectal immunizations to sites defined by their source of vascularization

We show that the distribution of specific antibodies and antibody-secreting cells in the intestine after oral and rectal immunizations corresponds to the vascularization and lymph drainage patterns of the gut. Oral immunizations induce antibody responses along the parts of the intestine connected to the superior mesenteric vessels and lymph ducts, whereas rectal immunizations induce antibody responses along the parts of the intestine associated with the inferior mesenteric vessels and ducts.

A hermeneutic textual analysis of suffering and caring in the peri-operative context

Hermeneutic text interpretation is discussed in this paper as a possible way of releasing nurses' knowledge, in order to develop a deeper understanding of professional caring. The text is a nurse's story, which has been gathered by means of the critical incident technique. The intention is to elicit the knowledge of professional caring in the stories and the language of caring science, which is concealed in a nurse's reality. Hermeneutic text interpretation through reading a text and having a dialogue with the nurse's reality will give a voice and a language to silent knowledge.

In vivo depletion of CD8+ cells does not affect primary maedi visna virus infection in sheep

T-cells have been implicated both, in promoting and reducing viral replication during lentivirus infection. CD8+ lymphocytes are believed to be important in controlling viral load through direct killing of virus-infected cells and by secretion of inhibitory chemokines and cytokines. To evaluate the role of CD8+ T-cells in the induction and control of the primary phase of a lentivirus infection, we have used a non-T-cell tropic lentivirus, maedi-visna virus (MVV), to study the initial pathogenesis and subsequent immune responses in sheep depleted in vivo of CD8+ cells. Sheep were depleted of CD8+ cells in both blood and efferent lymph for up to 14 days. No difference in MVV replication was observed in either the draining efferent lymph or lymph node of these sheep. Surprisingly, these animals displayed a normal induction of pCTL whereas the virus-specific proliferative responses were reduced. This could reflect either that a proportion of functional CD8+ lymphocytes remained in these animals, as suggested by the appearance of pCTLs, or that CD8+ cells are not required for control of primary MVV infection.

Semitendinosus tendon regeneration after harvesting for ACL reconstruction. A prospective MRI study

Utilisation of the semitendinosus and gracilis tendons in reconstruction of the anterior cruciate ligament (ACL) has become more common during the last few years. In recent studies a regeneration potential in the harvested tendons has been observed. In this study, 11 consecutive patients who underwent ACL reconstruction with a quadruple semitendinosus graft were examined 6-12 months postoperatively by MRI. Another two patients were examined within 2 weeks after surgery. The median age of the patients was 24 years and there were 8 males and 3 females. The right knee was involved in six patients and the left knee in five. A low-field 0.2 Tesla Siemens open MRI was used for examinations and T1 and T2 weighted transaxial sequences over the thigh and the knee joint were performed. In some instances, additional sagittal sequences were used. ROI analysis of the pixel value of the signal and area determinations on transaxial sequences was performed for both the involved and the healthy side. In 8 of the 11 patients examined 6-12 months postoperatively, a regeneration of the semitendinosus tendon with normal anatomical topographies to the level of the tibial plateau was found. Three of these eight patients were analysed more distally and fusion of the semitendinosus and gracilis tendons was found approximately 30 mm below the joint line before they inserted as a "conjoined tendon" into the pes anserinus. At the mid-thigh level, the semitendinosus muscle had a smaller area and a higher signal than that on the normal side. However, this difference was smaller in the patients showing normal distal tendon regeneration. This study indicates that the semitendinosus tendon has a strong potential for regeneration and that the muscle atrophy seems to be less in the patients with a more normalised distal insertion of the tendon in the pes anserinus.

Chronic hepatitis B in children in Gothenburg, Sweden

Sweden is a low prevalence area for hepatitis B, but the number of chronic carriers has increased during the last decade due to immigration. Out of a total of 120 children with identified chronic hepatitis B in Gothenburg, Sweden, 93 were investigated during the 2-year period 1994-95. The children had a mean age of 10.9 years and originated from 21 different countries. Most infections were discovered during various screening programmes after arrival in Sweden. A total of 90 of the 93 children were HBV-DNA positive by Amplicor HBV Monitor (Roche Diagnostics) and 58% (54/93) were HBeAg positive. All children either originated from areas with a high or medium prevalence of HBV infection (81/93, 87%) or were born in Sweden to mothers originating from high or medium prevalence countries (12/93, 13%). Three of these 12 children were vertically infected in spite of adequate immunoprophylaxis and 8 were born to mothers with undiscovered chronic HBV infection. In all, 34 children had mothers who were HBsAg positive. No overt case of transmission was notified in day-care centres or schools, or from a child to a non-immune parent. None of the children reported any symptoms of liver disease, but 38% (35/93) had elevated aminotransferases. Therefore, screening programmes are essential to identify chronic HBV infection in children in order to prevent transmission and to find individuals at risk of progressive liver damage who should be considered for treatment.

CD4(+) T-cells are required for the establishment of maedi-visna virus infection in macrophages but not dendritic cells in vivo

The role of CD4(+) lymphocytes in the establishment of lentivirus infection in macrophages has been studied in an in vivo system of lentivirus infection where CD4(+) lymphocytes are not the targets for infection. Using the non-T-cell-tropic lentivirus, maedi-visna virus (MVV), in CD4-depleted sheep, we have found that CD4(+) T cells were required for MVV infection in macrophages but not dendritic cells. CD4-depleted sheep had significantly lower levels of MVV-infected cells in lymph nodes and efferent lymph after MVV challenge in the drainage area of the lymph node. Due to the absence of virus in combination with the lack of CD4(+) T helper cells, virus-specific immune responses were reduced. There was delayed induction of cytotoxic T cell precursors, a marked reduction in virus-specific in vitro proliferative responses, and a delay in the appearance of MVV-specific antibodies. By contrast, CD4 depletion had no effect on the establishment of MVV infection in afferent lymph dendritic cells migrating from the skin infection site to the lymph node.

Evaluation of two adsorbents for diffusive sampling and thermal desorption-gas chromatographic analysis of monoterpenes in air

Tube type samplers with two different adsorbents, Chromosorb 106 and Tenax TA, were evaluated by laboratory experiments and field tests for simultaneous diffusive sampling of alpha-pinene, beta-pinene and delta 3-carene and subsequent thermal desorption-gas chromatographic analysis. No statistically significant effects of exposure time, concentrations of monoterpenes or relative humidity were found for samplers with Chromosorb 106 when running a factorial design, with the exception of the adsorption of delta 3-carene, for which some weak effects were noted. Samplers with Tenax TA were affected by the sampling time as well as the concentration for all terpenes, with a strong interaction effect between these two factors. The terpenes showed good storage stability on both adsorbents. No effect of back-diffusion was noted when using Chromosorb 106, while Tenax TA showed some back-diffusion effects. The uptake rates, in ml min-1, for the terpenes on Chromosorb 106 were 0.36 for alpha-pinene, 0.36 for beta-pinene and 0.40 for delta 3-carene. The corresponding average values on Tenax TA were 0.30 for alpha-pinene, 0.32 for beta-pinene and 0.38 for delta 3-carene. The field validation proved that diffusive sampling on Chromosorb 106 agreed well with pumped sampling on charcoal for stationary samples, while the personal samples indicated a discrepancy of 25% between Chromosorb 106 and charcoal samples. Tenax TA generally gave lower results than Chromosorb 106 in all field samples. Samplers packed with Chromosorb 106 could be used to monitor terpene levels in workplaces such as sawmills. The major advantages with this method are the sampling procedure, which is simple to perform compared to other techniques, the easily automated analysis procedure and the possibility to reuse the samplers.

Specific-antibody-secreting cells in the rectums and genital tracts of nonhuman primates following vaccination

To determine optimal strategies to induce specific-antibody-secreting cells (specific ASC) in the rectal and vaginal mucosae, we immunized monkeys with a prototype mucosal immunogen, cholera toxin (CT), given locally or via gastric or parenteral administration. Repeated rectal or vaginal CT immunizations induced strong mucosal and systemic ASC responses. The mucosal responses were, however, confined to the immunization sites and comprised high levels of both specific antitoxin immunoglobulin A (IgA) and IgG. Large numbers of specific IgA and IgG ASC were detected in cell suspensions from dissociated genital and rectal tissues, demonstrating local accumulation of effector B cells at these sites. Intragastric immunization with CT did not per se give rise to cervicovaginal or rectal ASC responses but did prime for a rectal IgA ASC response to local booster immunization. Both rectal and vaginal immunizations also induced circulating blood IgG ASC and IgA ASC. In conclusion, these results show that local administration of antigen to the rectal or vaginal mucosa results in higher ASC responses than systemic or distant mucosal delivery. Furthermore, both the vaginal and the rectal mucosae can serve as inductive sites for systemic ASC responses. These observations should be relevant to the development of vaccines against sexually transmitted diseases such as that caused by human immunodeficiency virus.

A comparison between patients' experiences of how their caring needs have been met and the nurses' patient classification--an explorative study

AIM

To examine whether patient classification carried out in accordance with the Oulu Patient Classification (OPC) method can measure the patient's caring needs in a reliable manner as seen from the patient's perspective.

BACKGROUND

On the basis of earlier research it can be established that there are differences between nurses' and patients' assessments of patients' caring needs. Research on patients' assessments of perceived caring needs and the care they receive in connection with patient classification does not seem to have interested researchers in caring science.

METHODS

The reliability from the patient's perspective is gauged by comparing the patient's perceived caring needs with the nurse's patient classification during a 24-h bed-day. Data was collected during a semi-structured interview with a total of 73 patients. Documentary analysis was carried out on the basis of patient classifications by 30 ward nurses.

FINDINGS

On the basis of the degree of correspondence between nursing care intensity experienced by the patients and the nurses' patient classification it was decided whether the patients' caring needs had been met. The results indicate, however, that patient classification as a gauging method has a built-in reductive function regarding the patient's need for care and nursing care intensity.

CONCLUSIONS

Nevertheless the OPC offers possibilities from a patient perspective of providing an overall picture of the patient's nursing care intensity and can therefore serve as a reliable basis for decisions concerning staff planning.

Multicellular and aggregative behaviour of Salmonella typhimurium strains is controlled by mutations in the agfD promoter

A colony morphology type is described in which cells of Salmonella typhimurium form a rigid multicellular network with expression of thin aggregative fimbriae that mediate tight intercellular bonds. Surface translocation of cells on plates and adherence to glass and polystyrene surfaces in biofilm assays are further characteristics of the morphotype. This morphotype (rdar) is normally expressed only at low temperature. However, in two unrelated S. typhimurium strains, spontaneous mutants were found forming rdar colonies independent of temperature. Allelic replacement proved a single point mutation in the promoter region of PagfD in each of the two mutants to be responsible for the constitutive phenotype of a multicellular behaviour. Transcription levels of the two divergently transcribed agf operons required for biogenesis of thin aggregative fimbriae by Northern blot analysis with gene probes for agfA and agfD as well as expression levels of AgfA by Western blotting were compared in the wild type, the constitutive mutants and their respective ompR and rpoS- derivatives. In the wild type the rdar morphotype and expression of thin aggregative fimbriae are restricted to low temperature on plates containing rich medium of low osmolarity, but biogenesis of thin aggregative fimbriae occurs upon iron starvation at 37 degrees C. In the upregulated mutants biogenesis of thin aggregative fimbriae is only abolished at high osmolarity at 37 degrees C and in the exponential phase in broth culture. Control of expression of thin aggregative fimbriae and rdar morphology takes place at the transcriptional level at the agfD promoter. A functional ompR allele is required, however an rpoS mutation abolishes transcription only in the wild type, but has no influence on expression of thin aggregative fimbriae in the constitutive mutants.

Abduction--a way to deeper understanding of the world of caring

In this article, abduction is discussed as a possible way of developing an epistemology for an autonomous caring science based on an ontology that requires deeper understanding of the world of caring. The intention is to elicit a more distinct caring-scientific pattern of knowledge based on the innermost core and historical conditions of caring. Abduction makes it possible to perceive connections on a deeper level and to penetrate in a way that reveals a richness of meaning, reflecting the true being in the dynamic process which is expressed in clinical reality. In the tradition of knowledge developed by Peirce, a synthesis of Hume's and Kant's tradition of knowledge, abduction is a fundamental idea. Peirce sees abduction as an operation of thought in which the recognition of underlying patterns makes a complex reality comprehensible. We regard the triad of abduction, induction and deduction as the basis for developing a caring-scientific epistemology where abduction makes a synthesizing abstraction possible and may implement understanding of deeper patterns.

Understanding the world of the patient, the suffering human being: the new clinical paradigm from nursing to caring

Discussions about a "new" paradigm--a more authentic, autonomous, and clinically practical form of nursing--have occurred for the last few years. A change of paradigm implies a change in the core of theory. The new core presupposes a return to the original historical conditions of caring. This article reports on a study that used a hermeneutical research approach to find basic patterns in different caring cultures. The patient's world stands out as a world of suffering. The patient's experiences of suffering, poor health, and illness are the starting point of the clinical paradigm.