Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study.

BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN: Qualitative research. PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS: Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.

Computational analysis of the potential energy surfaces of glycerol in the gas and aqueous phases: effects of level of theory, basis set, and solvation on strongly intramolecularly hydrogen-bonded systems.

The 126 possible conformations of 1,2,3-propanetriol (glycerol) have been studied by ab initio molecular orbital and density functional theory calculations in the gas and aqueous phases at multiple levels of theory and basis sets. The partial potential energy surface for glycerol as well as an analysis of the conformational properties and hydrogen-bonding trends in both phases have been obtained. In the gas phase at the G2(MP2) and CBS-QB3 levels of theory, the important, low-energy conformers are structures 100 and 95. In the aqueous phase at the SM5.42/HF/6-31G* level of theory, the lowest energy conformers are structures 95 and 46. Boltzmann distributions have been determined from these high-level calculations, and good agreement is observed when these distributions are compared to the available experimental data. These calculations indicate that the enthalpic and entropic contributions to the Gibbs free energy are important for an accurate determination of the conformational and energetic preferences of glycerol. Different levels of theory and basis sets were used in order to understand the effects of nonbonded interactions (i.e., intramolecular hydrogen bonding). The efficiency of basis set and level of theory in dealing with the issue of intramolecular hydrogen bonding and reproducing the correct energetic and geometrical trends is discussed, especially with relevance to practical computational methods for larger polyhydroxylated compounds, such as oligosaccharides.

A possible role for stable microtubules in intracellular transport from the endoplasmic reticulum to the Golgi apparatus.

The intracellular transport of secretory proteins involves at an early stage the formation of vesicles from transitional elements of the endoplasmic reticulum (ER) containing these proteins and the transfer of these vesicles to the cis-face of the Golgi apparatus. We propose that the latter transfer process does not occur by random diffusion, but is instead mediated by tracking along stable microtubules. To test this proposal, we have carried out double immunoelectron microscopic labeling experiments on frozen sections of HepG2 hepatoma cells secreting the protein human serum albumin (HSA). By a cycloheximide treatment protocol, the stage during which the transfer of newly synthesized HSA from the ER to the Golgi apparatus occurs in vivo was determined. Sections of the cells were then double immunolabeled using primary antibodies to HSA and to glu-tubulin, the latter specifically detecting stable microtubules. We observed a significantly high frequency of HSA-containing structures between the ER and the Golgi apparatus with which stable microtubules were closely associated. These results support the proposal that stable microtubules may play a critical role in directing the transfer process from the ER to the Golgi apparatus.

A soluble secretory protein is first concentrated in the endoplasmic reticulum before transfer to the Golgi apparatus.

A soluble secretory protein is usually present at a much higher concentration in the Golgi apparatus than in the endoplasmic reticulum (ER) inside eukaryotic secretory cells in the steady state. We show by immunoelectron microscopic experiments with the soluble secretory protein serum albumin, inside Hep-G2 human hepatoma cells in culture, that the secretory protein is first concentrated at isolated sites within the ER before it is transferred to the cis face of the Golgi apparatus. This is contrary to expectations of the bulk-flow hypothesis of ER-to-Golgi transfer, and it suggests the involvement of concentration and transfer mechanisms within the ER that have not previously been recognized.

Transfer of secretory proteins from the endoplasmic reticulum to the Golgi apparatus: discrimination between homologous and heterologous transfer in intact heterokaryons.

To examine aspects of the transfer of secretory proteins from the endoplasmic reticulum to the Golgi apparatus in situ, heterokaryons were formed between Hep G2 human hepatoma cells and WI-38 human fibroblasts. The cells were appropriately treated with cycloheximide before fusion, which emptied them of their respective secretory proteins, serum albumin for the Hep G2 cells and procollagen I for the WI-38 cells. After fusion was complete, the cycloheximide was washed out, protein synthesis was resumed, and the rates of reappearance of serum albumin and procollagen I in the two separated Golgi apparatuses within each heterokaryon were followed by immunofluorescence microscopy. Serum albumin was found to always reappear first in the Golgi apparatus contributed by the Hep G2 half of the heterokaryon, and procollagen I in the Golgi apparatus of the WI-38 half. These results suggest that the endoplasmic reticulum-to-Golgi apparatus transfer in situ is not simply a stochastic process but is either spatially restricted or exhibits cell-type specificity or both.

The specific interaction of helper T cells and antigen-presenting B cells. IV. Membrane and cytoskeletal reorganizations in the bound T cell as a function of antigen dose.

We have used double-immunofluorescence labeling to determine the surface distributions of LFA-1 and CD4, and the intracellular distributions of the cytoskeletal protein talin and of the microtubule organizing center (MTOC) of cloned Th cells in 1:1 cell couples with antigen (Ag)-specific APC of the B cell type (B-APC). The Th cell was directed to a peptide fragment of the Ag OVA in the context of IAd. The B-APC was the transfected A20 B hybridoma cell A20-HL, bearing on its surface a surface Ig specific for the hapten TNP, and pulsed with different concentrations of DNP-OVA. At sufficiently high doses of DNP-OVA (greater than 100 ng/ml), in essentially all couples, LFA-1, CD4, and talin were each concentrated at the Th cell membrane where it was in contact with the B-APC, and the MTOC inside the Th cell was reoriented to face the contact region. At lower doses of DNP-OVA (between 50 and 10 ng/ml), in all couples, LFA-1 and talin were concentrated at the Th/B-APC contact region, but the extent of CD4 clustering, MTOC reorientation, and Th cell proliferation all decreased with decreasing Ag dose. With no Ag, none of these effects was observed. These and other data indicate that two distinct signals are received by the Th cell that is specifically bound to its B-APC. The first signal, at low Ag doses, stimulates a linkage of LFA-1 and talin in the Th cell, and a specific LFA-1-mediated intercellular adhesion; the second signal, at higher Ag doses, is required to induce Th cell proliferation, with which the Th-MTOC reorientation and CD4 clustering are correlated.

Localization of high concentrations of phosphotyrosine-modified proteins in mouse megakaryocytes.

Phosphorylation of tyrosine residues of cellular proteins is a rare event and is considered to be related to the regulation of cellular growth, differentiation, and some forms of neoplastic transformation. Using high-affinity antibodies specific to phosphotyrosine (P-Tyr), we have shown the presence at high concentrations of P-Tyr-modified proteins in mouse bone-marrow megakaryocytes. Immunofluorescence microscopy of semithin frozen sections revealed that P-Tyr labeling was localized in a punctate pattern in the majority of the cytoplasm. The thin outer rim of the cytoplasm and the cell membrane was devoid of the label. Immunogold electron microscopy of ultrathin frozen sections showed that P-Tyr labeling was concentrated mostly on the membranes of the vesicles in the cytoplasm. The membrane demarcation system characteristic of megakaryocytes was not labeled. The intensity of P-Tyr labeling varied from one megakaryocyte to another. These results suggest that tyrosine phosphorylation of specific proteins might be correlated with the developmental stage of megakaryocytes, possibly related to the formation and deposition of the granules.

The specific direct interaction of helper T cells and antigen-presenting B cells. II. Reorientation of the microtubule organizing center and reorganization of the membrane-associated cytoskeleton inside the bound helper T cells.

We have produced and investigated cell couples formed between cloned Th cells or T hybridoma cells, and either Ag-presenting B hybridoma or B lymphoma cells. The specific direct interaction between a Th and B-APC is here demonstrated by two rearrangements occurring inside the bound Th cell; the MTOC (and presumably the GA) is oriented to face the cell contact region with the B cell, and a membrane-associated cytoskeletal protein, talin, becomes concentrated under the contacting Th membrane. In the absence of the specific Ag or the correct Ia determinant, nonspecific T-B cell couples form that are morphologically indistinguishable from specific cell couples in the light microscope, but neither the MTOC nor the talin rearrangement occurs inside the bound T cell of such nonspecific couples. Furthermore, Ag processing by the B cell is required to produce the MTOC and talin rearrangements within the T cell in specific T-B couples. In the case of allogeneic Th-B cell couples, similar specific MTOC and talin rearrangements are observed inside the Th. Extracellular Ca2+ is required for the MTOC orientation to occur inside the specifically bound Th cell, but not for the talin rearrangement. It is proposed that the MTOC (and GA) reorientation and the talin rearrangement are involved in the directed secretion of GA-derived lymphokines from the Th cell to the bound B cell.

On the transfer of integral proteins into membranes.

We have earlier proposed a molecular mechanism for the translocation of hydrophilic proteins across membranes that accounts for the experimental facts and meets the restrictions that we stipulate for such a mechanism. In particular, the restrictions are that translocation occurs by successive segments of the polypeptide chain and that the ionic groups of the polypeptide remain in contact with water throughout the translocation process. The evidence indicates that the transfer of integral proteins into membranes very likely uses the same molecular machinery as does the translocation of hydrophilic proteins across membranes. Here we show how the mechanism we have proposed for translocation can also be utilized in the intercalation of known types of integral proteins, accounting for their specific topologies in the membrane.

On the translocation of proteins across membranes.

Many proteins of intracellular organelles are first synthesized in the cytoplasm and are then specifically transferred across the membranes of the organelles. On the assumption that these transfers all occur by the same basic mechanism, we enumerate the rather stringent requirements that the mechanism must satisfy. A unitary molecular mechanism is then proposed that meets these requirements.

Disulfide bonds and the translocation of proteins across membranes.

We are concerned with the mechanisms whereby hydrophilic proteins synthesized in the cytoplasm are translocated across one or two membranes into different cellular organelles. On the basis of a model of the translocation process to be described elsewhere, we propose an explanation of previous findings that the in vitro translocation across the endoplasmic reticulum of secretory proteins of higher eukaryotic cells appears to be obligatorily co-translational (i.e., occurs only while the polypeptide chain is being synthesized on the ribosome). We suggest that in vitro the intrachain disulfide bonds of the polypeptide rapidly form after it is released from the ribosome; the three-dimensional conformation of the chain is thereby stabilized and cannot undergo the unfolding that is required for post-translational translocation. In accord with this proposal, we show that the secretory preprotein human preprolactin, after translation and release from the ribosome, can indeed undergo translocation across endoplasmic reticulum membranes in vitro if the medium is sufficiently reducing. Those polypeptides that, in the absence of reducing agents, can be post-translationally translocated in vitro across bacterial, mitochondrial, and other types of membranes may generally lack intrachain disulfide bonds.

Talin is phosphorylated on tyrosine in chicken embryo fibroblasts transformed by Rous sarcoma virus.

We have examined the extent of tyrosine phosphorylation of talin, a component of the cytoskeleton localized in the focal adhesions and, therefore, a potential substrate of p60v-src, the transforming protein of Rous sarcoma virus. p60v-src is a tyrosine kinase that induces high levels of phosphotyrosine and the disorganization of the cytoskeleton in transformed cells. With a polyclonal antibody utilized in a previous study [Maher, P. A., Pasquale, E. B., Wang, J. Y. J. & Singer, S. J. (1985) Proc. Natl. Acad. Sci. USA 82, 6576-6580] for the detection of tyrosine-phosphorylated proteins, we have detected phosphotyrosine residues in talin molecules immunoprecipitated from Rous sarcoma virus-transformed, but not normal, chicken embryo fibroblasts. Phospho amino acid analysis of talin from the infected cells confirmed the presence of phosphotyrosine, in addition to phosphoserine and phosphothreonine. The extent of tyrosine modification in talin was compared to that in vinculin, the other focal adhesion component previously found to contain enhanced levels of phosphotyrosine in various retrovirus-transformed cells. A considerably (3 times) larger fraction of the talin than of the vinculin molecules was found to be phosphorylated on tyrosine. The phosphorylation of talin on tyrosine may be crucial for the expression of the abnormal morphology characteristic of cells transformed by Rous sarcoma virus.

Cytoskeletal organization, vinculin-phosphorylation, and fibronectin expression in transformed fibroblasts with different cell morphologies.

Neoplastic transformation of fibroblasts results in widely different cell morphologies. We have attempted to correlate cell morphology with cytoskeletal organization and fibronectin expression in murine and avian fibroblasts transformed by a diverse group of viral and chemical agents. The distribution of vinculin, alpha-actinin, actin, and surface fibronectin was studied, and, where appropriate, also the extent of phosphotyrosine modification of vinculin. Irrespective of the transforming agent we found that increased cell rounding was generally correlated with a reduction in vinculin-containing focal adhesions, a dissolution of microfilament bundles, and a reduction of extracellular fibronectin. In contrast, spindle-shaped fibroblasts expressed relatively high levels of surface fibronectin. Reorganization of vinculin, actin, and alpha-actinin into rosette-like structures was observed in polygonal or rounded cells transformed by viruses encoding tyrosine kinases, but was not seen in fibroblasts transformed by agents without associated tyrosine kinase activity or in spindle-shaped cells. No correlation was found between the extent of phosphotyrosine modification of vinculin and the extent of cell rounding. Irrespective of cell morphology, the extent of tyrosine phosphorylation of vinculin was high in all cells transformed by viruses carrying the src gene, but low in those transformed by viruses expressing the fps gene. Our results indicate that the morphology of a transformed cell is determined by a combination of several factors which are affected to different extents by different transforming agents.

On the mechanism of unidirectional killing in mixtures of two cytotoxic T lymphocytes. Unidirectional polarization of cytoplasmic organelles and the membrane-associated cytoskeleton in the effector cell.

In mixtures of two CTL of the type a anti-b and b anti-c, only the latter is lysed; i.e., killing is unidirectional. Here, we show that two profound types of changes occur in the effector CTL but not in the target CTL upon formation of couples between them. One is that the microtubule organizing center (and presumably the Golgi apparatus that is invariably colocalized with it) is reoriented inside the effector CTL to face the bound target CTL. This unidirectional reorientation, it is proposed, serves to direct putative cytotoxic secretory components derived from the Golgi apparatus of the effector cell to the site of cell-cell binding. The second unidirectional change is in the membrane-associated cytoskeleton of the effector CTL in the area of target cell binding. The cytoskeletal protein talin, but not any of four other such proteins assayed, is highly concentrated at the contacting membrane of the effector CTL, while it is uniformly distributed over the entire membrane of the bound target CTL. This localized, massive cytoskeletal reorganization may reflect a mechanism to protect the membrane of the effector CTL from the effects of putative cytotoxic components secreted by the effector cell into the intercellular space between it and the target cell.

Phosphotyrosine-containing proteins are concentrated in focal adhesions and intercellular junctions in normal cells.

We have used a high-affinity polyclonal antibody directed against phosphotyrosine (P-Tyr) to localize P-Tyr-containing proteins in normal and transformed cells in culture by immunofluorescence microscopy experiments. The distribution of the proteins with modified tyrosine was compared with that of F-actin in these cells. Cells infected with Abelson murine leukemia virus were found to contain elevated levels of P-Tyr, as expected. Various permanent lines of fibroblastic and epithelial cells exhibited lower, but easily detectable, levels of P-Tyr. The P-Tyr in fibroblasts was concentrated at the focal contacts at the termini of actin-containing microfilament bundles and, in the epithelial cells examined, at the intercellular junctions. Early passages of primary cultures of chicken embryo fibroblasts and chicken embryo heart cells also showed detectable levels of P-Tyr in focal contacts and cell-cell junctions. However, P-Tyr was not detectable in later passages of chicken embryo fibroblasts. The concentration of P-Tyr-containing proteins in intercellular junctions in normal cells suggests that these are sites of significant biochemical regulatory activities which may be important in the control of normal cell adhesivity, motility, and shape.

The reorientation of the Golgi apparatus and the microtubule-organizing center in the cytotoxic effector cell is a prerequisite in the lysis of bound target cells.

This investigation is concerned with the detailed mechanisms of cytotoxicity, and in particular, with early cell surface and intracellular events that occur upon the binding of a cytotoxic effector cell to its susceptible target. In earlier studies, we have shown by immunofluorescence microscopy that when cloned natural killer (NK) and cytolytic T lymphocyte (CTL) cells bind to susceptible target cells, a rapid and coordinate reorientation of the perinuclear Golgi apparatus and the microtubule-organizing center (MTOC) occurs inside the effector cell so that the two organelles face the bound target. It was proposed that the purpose served by this reorientation is to direct Golgi-derived secretory vesicles, containing one or more cytotoxic components, to the area of target cell binding. In order to establish more firmly that this reorientation of the two organelles is an essential early event in cytotoxicity, we have performed three different types of experiments. 1) Upon binding cloned effector cells to susceptible targets in the presence of Mg+2 but absence of Ca+2, conditions in which no killing occurs, we found that no reorientation of the MTOC in the effector cell is induced; however, the addition of CA+2 to these cell couples results in a rapid MTOC reorientation. 2) With a lysis-defective subclone derived from a cytolytic NK clone, binding to target cells did not induce an MTOC reorientation in the defective killer cell. 3) In multitarget conjugates formed with single CTL, the MTOC in the CTL was oriented to face that one target cell which was in the process of lysis at the time. These results, together with our earlier findings, strongly indicate that a Golgi/MTOC reorientation inside the target-bound effector cell is a pre-requisite for the effective lysis of the target. They also reveal the existence, previously unrecognized, of a specific signaling mechanism from the viable target cell to the effector cell, which must be involved in the triggering of this Golgi/MTOC reorientation. These conclusions are consistent with the proposal that a polar cytotoxic secretory mechanism is responsible for target cell lysis.