Oncology patients' experience at the interface between hospital and community care: a mixed method investigation

Introduction

Oncology patients often experience breakdowns in care when transitioning between care settings.

Aims and objectives

To examine the experience of oncology patients at the transition between hospital and community care and identify factors which affect fragmentation.

Methods

We used a complementary mixed method approach. Qualitative phase: semi-structured interviews and focus groups were conducted with patients and their caregivers, nurses, social workers, physicians and medical administrators. Quantitative phase: a survey was administered to 400 oncology patients of a large tertiary medical center in Northern Israel. Patients who were discharged from the hospital completed a validated questionnaire on their transition from the hospital to the community and on their perceptions of the quality of their primary care. The surveys were administered in Hebrew, Arabic, and Russian.

Results

From the preliminary analysis of the qualitative data four broad themes emerged: (1) responsibility for care, (2) administrative and bureaucratic burden, (3) informal routes of communication, and (4) cultural barriers. The regression analyses examined the effect of patient characteristics (gender, age, education, income, health status, and language group) and showed that patients' language accounted for most of the variance in quality scores. Russian speaking patients reported poorer quality of care and Arabic speaking patients reported better quality of care, than Hebrew speakers, in all primary care domains. Both Arabic and Russian speakers scored significantly higher on the Care Transition Measure than Hebrew speakers.

Conclusions

The differences between sub-groups found here suggest that avoidable variations in care exist. To enable a more streamlined process, cultural issues need to be addressed at the interface between care settings. Further research should examine the causes for such differences.

Despite GABAergic neurotransmission, GABAergic innervation does not compensate for the defect in glycine receptor postsynaptic aggregation in spastic mice

In the hypoglossal nucleus of wild-type mice, early mixed glycinergic-GABAergic inhibitory transmission becomes mainly glycinergic during postnatal maturation. In spastic mice (SPA), a model of human hyperekplexic syndrome, an insertion into the gene of the glycine receptor (GlyR) beta subunit results in a decreased accumulation of GlyRs at postsynaptic sites and an impaired glycinergic neurotransmission. In SPA mice displaying a mild phenotype (B6C3Fe strain), a compensatory process involving an increased aggregation of GABA(A) receptors (GABA(A)Rs) at postsynaptic sites was proposed to explain survival of mutant animals until adulthood. However, C57BL/6J strain SPA mice which express a lower amount of GlyR beta subunit die 2-3 weeks after birth, suggesting that GABAergic compensation does not necessarily take place. We performed a morphofunctional study of inhibitory synapses in the developing hypoglossal nucleus of C57BL/6J SPA mice. In this mutant, the inhibitory synaptic activity was mainly GABAergic. Accordingly, we observed a developmental loss of glycinergic presynaptic terminals and an increase in the density of GABAergic presynaptic terminals during the first two postnatal weeks. In addition, while C57BL/6J SPA mice displayed a strong impairment in GlyR aggregation at postsynaptic loci, the proportion of inhibitory presynaptic terminals facing diffuse GABA(A)Rs significantly increased during development. Our results suggest crosstalk between postsynaptic and presynaptic elements, leading to the developmental regulation of the presynaptic terminal neurotransmitter content according to the level of postsynaptic GlyR aggregation. They also indicate that GABAergic neurotransmission does not compensate for defects in GlyR postsynaptic aggregation leading to spastic syndrome in C57BL/6J SPA mice.

Extrasynaptic and postsynaptic receptors in glycinergic and GABAergic neurotransmission: a division of labor?

Glycine and GABA mediate inhibitory neurotransmission in the spinal cord and central nervous system. The general concept of neurotransmission is now challenged by the contribution of both phasic activation of postsynaptic glycine and GABA(A) receptors (GlyRs and GABA(A)Rs, respectively) and tonic activity of these receptors located at extrasynaptic sites. GlyR and GABA(A)R kinetics depend on several parameters, including subunit composition, subsynaptic localization and activation mode. Postsynaptic and extrasynaptic receptors display different subunit compositions and are activated by fast presynaptic and slow paracrine release of neurotransmitters, respectively. GlyR and GABA(A)R functional properties also rely on their aggregation level, which is higher at postsynaptic densities than at extrasynaptic loci. Finally, these receptors can co-aggregate at mixed inhibitory postsynaptic densities where they cross-modulate their activity, providing another parameter of functional complexity. GlyR and GABA(A)R density at postsynaptic sites results from the balance between their internalization and insertion in the plasma membrane, but also on their lateral diffusion from and to the postsynaptic loci. The dynamic exchange of receptors between synaptic and extrasynaptic sites and their functional adaptation in terms of kinetics point out a new adaptive process of inhibitory neurotransmission.

Molecular characterization of banana streak acuminata Vietnam virus isolated from Musa acuminata siamea (banana cultivar)

An isolate of banana streak virus (BSV) that does not also occur as an integrant in the Musa balbisiana genome was sought in order to investigate the biological role of BSV in the evolution of either the Musa genome or of the virus itself. We isolated BSV virions from a Musa acuminata siamea accession from Vietnam and sequenced the entire viral genome. The molecular organization is similar to that described for other BSV but slightly larger (7801 bp vs. 1611-7568 bp), and ORF I has a non-conventional start codon. This genome was sufficiently different to propose it as a member of a distinct species named Banana streak virus strain acuminata Vietnam (BSAcVNV).

Molecular analysis of a full-length sequence of a new yam badnavirus from Dioscorea sansibarensis

Badnavirus-like particles were observed by ISEM in viral preparations from yam (Dioscorea sansibarensis) leaves from Benin. Use of the viral preparation as template for PCR amplification with badnavirus-specific primers gave rise to a 579-bp product with most nucleotide identity (70.8%) to Dioscorea alata bacilliform virus (DaBV, Accession numbers X94575-X94582), the only other yam badnavirus sequenced to date. A full-length badnavirus sequence was generated, which consisted of 7261 nucleotides with a typical Badnavirus genome organisation. The full-length sequence shared most identity (61.9%) to DaBV (Accession numbers X94575-X94582) and hence represents a member of a new badnavirus species termed Dioscorea sansibarensis bacilliform virus (DsBV).

Liver transplantation at Red Cross War Memorial Children's Hospital

The liver transplant programme for infants and children at Red Cross War Memorial Children's Hospital is the only established paediatric service in sub-Saharan Africa. Referrals for liver transplant assessment come from most provinces within South Africa as well as neighbouring countries.

PATIENTS AND METHODS

Since 1987, 81 children (range 6 months-14 years) have had 84 liver transplants with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (48), metabolic (7), fulminant hepatic failure (10), redo transplants (3) and other (16). Four combined liver/kidney transplants have been performed. Fifty-three were reduced-size transplants with donor/recipient weight ratios ranging from 2:1 to 11:1 and 32 children weighed less than 10 kg.

RESULTS

Sixty patients (74%) survived 3 months-14 years post-transplant. Overall cumulative 1- and 5-year patient survival figures are 79% and 70% respectively. However, with the introduction of prophylactic intravenous ganciclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the 1-year patient survival is 90% and the projected 5-year paediatric survival is > 80%. Early (< 1 month) post-liver-transplant mortality was low. Causes include primary malfunction (1), inferior vena cava thrombosis (1), bleeding oesophageal ulcer (1), sepsis (1) and cerebral oedema (1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths), Epstein-Barr virus (EBV)- related post-transplantation lymphoproliferative disease (12 patients, 7 deaths) and cytomegalovirus (CMV) disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in 3 patients was complicated by chronic rejection (1) and TB-drug-induced subfulminant liver failure (1).

CONCLUSION

Despite limited resources, a successful paediatric programme has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors because of infection with HBV and human immunodeficiency virus (HIV) leads to significant waiting-list mortality and infrequent transplantation.

Overview of a paediatric renal transplant programme

INTRODUCTION

Renal transplantation is the therapy of choice for children with end-stage renal failure. There are many challenges associated with a paediatric programme in a developing country where organs are limited.

METHODS

A retrospective review was undertaken of 149 paediatric renal transplants performed between 1968 and 2006 with specific emphasis on transplants performed in the last 10 years. Survival of patients and grafts was analysed and specific problems related to drugs and infections were reviewed.

RESULTS

On review of the total programme, 60% of the transplants have been performed in the last 10 years, with satisfactory overall patient and graft survival for the first 8 years post transplant. At this point, transfer to adult units with non-compliance becomes a significant problem. Rejection is less of a problem than previously but infection is now a bigger issue--specifically tuberculosis (TB), cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections with related complications. A wide variety of drugs are available for tailoring immunosuppression to minimise side-effects.

CONCLUSION

It is possible to have a successful paediatric transplant programme in a developing country. However, to improve long-term outcomes certain issues need to be addressed, including reduction of nephrotoxic drugs and cardiovascular risk factors and providing successful adolescent to adult unit transition.

Developmental dissociation of presynaptic inhibitory neurotransmitter and postsynaptic receptor clustering in the hypoglossal nucleus

At postsynaptic densities of mouse hypoglossal motoneurons, the proportion of glycine receptors co-clustered with GABAA receptors increases from neonatal to adult animals, suggesting that mixed synapses might play a greater role in adult synaptic inhibition. We visualized the presynaptic correlates of these developmental changes using immunocytochemistry. At P5, presynaptic terminals contained glycine and GlyT2 and/or GABA and GAD65, but at P15, the majority of inhibitory terminals contained glycine and GlyT2 only. The GABAergic component of evoked inhibitory postsynaptic currents in HMs decreased strongly between P5 and P15. Similarly, miniature inhibitory postsynaptic currents evolved from mainly glycinergic and mixed glycinergic/GABAergic events at P3-5 to predominantly glycinergic currents at P15. These results indicate that the decrease in the proportion of functional mixed inhibitory synapses with maturation results from a loss of the ability of presynaptic terminals to release both neurotransmitters during development while co-aggregation of GlyRs + GABAARs at postsynaptic loci remained.

Molecular ecology and emergence of tropical plant viruses

An appreciation of the risks caused by emergent plant viruses is critical in tropical areas that rely heavily on agriculture for subsistence and rural livelihood. Molecular ecology, within 10 years, has unraveled the factors responsible for the emergence of several of the economically most important tropical plant viruses: Rice yellow mottle virus (RYMV), Cassava mosaic geminiviruses (CMGs), Maize streak virus (MSV), and Banana streak virus (BSV). A large range of mechanisms--most unsuspected until recently--were involved: recombination and synergism between virus species, new vector biotypes, genome integration of the virus, host adaptation, and long-distance dispersal. A complex chain of molecular and ecological events resulted in novel virus-vector-plant-environment interactions that led to virus emergence. It invariably involved a major agricultural change: crop introduction, cultural intensification, germplasm movement, and new genotypes. A current challenge is now to complement the analysis of the causes by an assessment of the risks of emergence. Recent attempts to assess the risks of emergence of virulent virus strains are described.

Occurrence of Cacao swollen shoot virus in Litimé, the Main Cocoa-Producing Area of Togo

Cacao swollen shoot disease, first described from Ghana on Theobroma cacao in 1922, was identified in Togo in 1955 (4) in Kloto, a minor cocoa-producing area. Litimé is the main production zone in the country. However, its share of production has fallen from approximately 75% of national production in the 1980s to 55% currently because of aging plantations and new swollen shoot foci in this region that had previously been free of the disease. This disease is caused by Cacao swollen shoot virus (CSSV), of which the first isolate to be studied molecularly (Agoul) came from Kloto (1). Since then, the different cocoa-producing regions have been surveyed on several occasions and swollen shoot foci were detected for the first time in Litimé at the end of the 1990s. During 2000, symptomatic leaves were taken from trees which exhibited characteristic symptoms of the disease including swellings on fan branches and chupons, and red vein banding on young flush leaves. The existence of the virus was confirmed using immunosorbent electron microscopy (2) with a composite polyclonal Banana streak virus/Sugarcane bacilliform virus antiserum supplied by B. Lockhart and using polymerase chain reaction amplification with CSSV-specific primers (3). Degenerate primers for CSSV detection were designed in the 5' region (the first 350 amino acids) of open reading frame (ORF3) because this region of the CSSV genome was found to be highly conserved among available full-length CSSV sequences. An isolate from the Litimé area (Wobe 12) was sequenced completely (Genbank Accession No. AJ781003), revealing that it shared a nucleotide sequence identity of only 77% with Agou1. Since the initial observations, the disease has spread rapidly and approximately 60% of the plots in Litimé contain infected trees. Hence, there is an urgent need for a program to rogue infected trees and replant with tolerant material. Moreover, this situation is a threat to cocoa plantations in neighboring Ghana, where numerous eradication operations to control this disease have been launched. References: (1) L. Hagen et al. Virology 196:619, 1993. (2) B. E. L. Lockhart et al. Phytopathology 82:691, 1992. (3) E. Muller et al. J. Virol. Methods 93:15, 2001. (4) M. Partiot et al. Café Cacao Thé 22:217, 1978.

Glycine receptors and GABA receptor alpha 1 and gamma 2 subunits during the development of mouse hypoglossal nucleus

In the hypoglossal nucleus, GABA and glycine mediate inhibition at separate or mixed synapses containing glycine receptors (GlyRs) and/or GABA(A) receptors (GABA(A)Rs). The functional development of mixed inhibitory synapses depends on the brain area studied, but their relative proportion to total synapses generally decreases with time. We have determined the sequential process of inhibitory synapse maturation in the hypoglossal nucleus in vivo. Immunocytochemistry and confocal microscopy were used for codetection of VIAAT, the common presynaptic vesicular transporter of glycine and GABA, GlyRs, GABA(A)R alpha1 and gamma2 subunits, and gephyrin, the scaffold protein implicated in the synaptic localization of inhibitory receptors. In E17 embryos, GlyRs were already clustered while GABA(A)R alpha1 and gamma2 subunit immunoreactivity (IR) displayed both diffuse and clustered patterns. Quantitative analysis at this stage revealed that the majority of GlyR clusters were apposed to VIAAT-IR accumulation and that 30% of them colocalized with gamma2GABA(A)R clusters. This proportion increased with age to 50% at P30. GlyR clusters that did not colocalize with gamma2GABA(A)R clusters were associated with GABA(A)R gamma2 diffuse IR. Interestingly, the percentage of GlyR clusters surrounded by GABA(A)R gamma2 diffuse IR decreased with age, while GlyR clusters colocalized with gamma2GABA(A)R clusters increased. The developmental coclustered pattern of gephyrin and GABA(A)R alpha1 and gamma2 subunits paralleled the coclustered pattern of GlyRs and GABA(A)R alpha1 and gamma2 subunits. Our results indicate that the proportion of GlyR-GABA(A)R coclusters increases until adulthood. A developmental sequence of the postsynaptic events is proposed in which diffuse extrasynaptic GABA(A)Rs accumulate at inhibitory synapses to form postsynaptic clusters, most of them being colocalized with GlyR clusters in the adult.

Molecular variability analysis of five new complete cacao swollen shoot virus genomic sequences

Cacao swollen shoot virus (CSSV), a member of the family Caulimovi-ridae, genus Badnavirus occurs in all the main cacao-growing areas of West Africa. We amplified, cloned and sequenced complete genomes of five new isolates, two originating from Togo and three originating from Ghana. The genome of these five newly sequenced isolates all contain the five putative open reading frames I, II, III, X and Y described for the first sequenced CSSV isolate, Agou1 originating from Togo. Their genomes have been aligned with the genome of Agou1. The nucleotide and amino acid sequence identities between isolates have been calculated and a phylogenetic analysis has been made including other pararetroviruses. Maximum nucleotide sequence variability between complete genomes of CSSV isolates was 29.4%. Geographical differentiation between isolates appears more important than differentiation between mild and severe isolates. ORF X differs greatly in size and sequence between the Togolese isolates Nyongbo2 and Agou1, and the four other isolates, its functional role is therefore clearly questionable.

Desensitization of homomeric alpha1 glycine receptor increases with receptor density

Variations in the number of receptors at glycinergic synapses are now established and are believed to contribute to inhibitory synaptic plasticity. However, the relation between glycine receptor (GlyR) kinetics and density is still unclear. We used outside-out patch-clamp recordings and fast-flow application techniques to resolve fast homomeric GlyRalpha1 kinetics and to determine how the functional properties of these receptors depend on their density and on the presence of the anchoring protein gephyrin. The expression of GlyRs in human embryonic kidney cells increased with time and was correlated with an increase in GlyR desensitization at 2 days after transfection. Cotransfection of homomeric GlyRalpha1 bearing the gephyrin-binding site with gephyrin also increased desensitization but at 1 day after transfection compared with transfections of homomeric GlyRalpha1 without gephyrin. This increase results from the occurrence of a fast desensitization component and short applications of a saturating concentration of glycine suffice to promote a rapidly entered desensitized closed state. The level of desensitization changed neither the EC(50) value nor the Hill coefficient of the glycine dose-response curves because the amplitude of the current was measured at the peak of the responses. These results demonstrate that variations in GlyR density during cluster formation result from a change in GlyR efficiency due to modifications in their desensitization properties.